Provider Demographics
NPI:1902145188
Name:KEVIN GERARD KELLY
Entity Type:Organization
Organization Name:KEVIN GERARD KELLY
Other - Org Name:KEVIN G. KELLY, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-332-5901
Mailing Address - Street 1:13150 HIGHWAY 43
Mailing Address - Street 2:SUITE 10
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-4558
Mailing Address - Country:US
Mailing Address - Phone:256-332-5901
Mailing Address - Fax:256-332-6911
Practice Address - Street 1:13150 HIGHWAY 43
Practice Address - Street 2:SUITE 10
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-4558
Practice Address - Country:US
Practice Address - Phone:256-332-5901
Practice Address - Fax:256-332-6911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-07
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health