1972543064 NPI number — KARL DAVID KELLEY MD

Table of content: CHRIS GUTHRIE (NPI 1518101781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972543064 NPI number — KARL DAVID KELLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
KARL
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1972543064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4059 KEITH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37172-6971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-384-6222
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 N L ROGERS WELLS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLASGOW
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42141-1300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-659-5555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  38748 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 46833 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3897033 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 10021964 . This is a "OMNICARE TENNCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3897036 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00357334 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: P00241188 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3809694 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4086997 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4124223 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 50007338 . This is a "PASSPORT HEALTH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 41090 . This is a "TLC TENNCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4124510 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 64086663 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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