Provider Demographics
NPI:1649351982
Name:NEELY, KENNETH W (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:NEELY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1223 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2607
Mailing Address - Country:US
Mailing Address - Phone:321-725-4505
Mailing Address - Fax:321-409-8932
Practice Address - Street 1:1223 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-725-4505
Practice Address - Fax:321-409-8932
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0043115207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069717600Medicaid
FL069717600Medicaid
FL15936XMedicare PIN
FLE56069Medicare UPIN