1013193705 NPI number — KELLIE ELIZABETH FLIPPIN MD

Table of content: MR. GARY DENNIS O BEREDO (NPI 1326090564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013193705 NPI number — KELLIE ELIZABETH FLIPPIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLIPPIN
Provider First Name:
KELLIE
Provider Middle Name:
ELIZABETH
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:
RIZZIERI
Provider Other First Name:
KELLIE
Provider Other Middle Name:
BRENNAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013193705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2132 DRUID RD E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33764-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-259-1520
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62301-2834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-223-8400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/14/2008

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: 207RH0003X , with the licence number:  036156080 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PENDING , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 206287 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5908517 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013193705 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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