1972593820 NPI number — KELLI TICE WELLS MD

Table of content: KELLI TICE WELLS MD (NPI 1972593820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972593820 NPI number — KELLI TICE WELLS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELLS
Provider First Name:
KELLI
Provider Middle Name:
TICE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1972593820
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1295 W FAIRFIELD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32501-1107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-595-6501
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1295 W FAIRFIELD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32501-1107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-595-6500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2005

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: 208M00000X , with the licence number:  ME82944 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: ME82944 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009978895 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59176263 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 262522900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06241 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P00195990 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7804499 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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