1306807979 NPI number — KELLY G MCQUEEN DO

Table of content: KELLY G MCQUEEN DO (NPI 1306807979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306807979 NPI number — KELLY G MCQUEEN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCQUEEN
Provider First Name:
KELLY
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRAY
Provider Other First Name:
KELLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306807979
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
276 FIELDSTONE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24263-1215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-224-3900
Provider Business Mailing Address Fax Number:
423-224-3901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2204 PAVILION DR
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-4657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-224-3900
Provider Business Practice Location Address Fax Number:
423-224-3901
Provider Enumeration Date:
03/31/2006

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: 207Q00000X , with the licence number:  0102203973 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 1209 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1306807979 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1509015 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00878625 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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