1689768285 NPI number — GREGORY P. KELLEY D.O. INC.

Table of content: (NPI 1689768285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689768285 NPI number — GREGORY P. KELLEY D.O. INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREGORY P. KELLEY D.O. INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KELLEY FAMILY CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689768285
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13190 NE 23RD STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHOCTAW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-769-7201
Provider Business Mailing Address Fax Number:
405-769-4034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13190 NE 23RD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHOCTAW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-769-7201
Provider Business Practice Location Address Fax Number:
405-769-4034
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KELLEY
Authorized Official First Name:
NAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
405-769-7201

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  2127 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 452023528002 . This is a "BC/BS FEDERAL" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: C2138 . This is a "BLUELINCS HMO" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 452023528002 . This is a "CGS CLAIMS" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 4335747 . This is a "AETNA HEALTHCARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 452023528002 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 73020A002 . This is a "TRICARE SOUTH /LIFE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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