Provider Demographics
NPI:1801897855
Name:VINCENT, WILLIAM KELLY (MD, FASAM)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:KELLY
Last Name:VINCENT
Suffix:
Gender:M
Credentials:MD, FASAM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 PHILLIP STONE WAY
Mailing Address - Street 2:
Mailing Address - City:CENTRAL CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42330-1929
Mailing Address - Country:US
Mailing Address - Phone:270-754-3494
Mailing Address - Fax:270-754-3494
Practice Address - Street 1:222 PHILLIP STONE WAY
Practice Address - Street 2:
Practice Address - City:CENTRAL CITY
Practice Address - State:KY
Practice Address - Zip Code:42330-1929
Practice Address - Country:US
Practice Address - Phone:270-754-3494
Practice Address - Fax:270-754-3499
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36099207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64017379Medicaid
KY64017379Medicaid
KY0652406Medicare PIN