1376871426 NPI number — KELSEY CHARLOTTE O'MARA PA-C

Table of content: KELSEY CHARLOTTE O'MARA PA-C (NPI 1376871426)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376871426 NPI number — KELSEY CHARLOTTE O'MARA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'MARA
Provider First Name:
KELSEY
Provider Middle Name:
CHARLOTTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROWN
Provider Other First Name:
KELSEY
Provider Other Middle Name:
CHARLOTTE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376871426
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21890
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-409-9925
Provider Business Mailing Address Fax Number:
502-919-9780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 EXECUTIVE PARK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-855-7200
Provider Business Practice Location Address Fax Number:
502-855-7201
Provider Enumeration Date:
12/01/2009

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: 363A00000X , with the licence number:  PA1333 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 10001499A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0314133 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12060975 . This is a "CAQH PROVIDER ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1700235 . This is a "WELLCARE OF KY PROVIDER ID NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100155270 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: CS1828800128 . This is a "CARESOURCE ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000001202435 . This is a "ANTHEM PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 300018062 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 98745KYIP . This is a "AETNA BETTER HEALTH" identifier . This identifiers is of the category "OTHER".




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