Provider Demographics
NPI:1033154810
Name:KELLY MEDICAL SERVICES CORPORATION LLC
Entity Type:Organization
Organization Name:KELLY MEDICAL SERVICES CORPORATION LLC
Other - Org Name:KELLY MEDICAL CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:DABBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-693-1000
Mailing Address - Street 1:PO BOX 634712
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-4712
Mailing Address - Country:US
Mailing Address - Phone:888-203-1274
Mailing Address - Fax:
Practice Address - Street 1:454 MCDOWELL ST
Practice Address - Street 2:
Practice Address - City:WELCH
Practice Address - State:WV
Practice Address - Zip Code:24801-2029
Practice Address - Country:US
Practice Address - Phone:304-436-8461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV007378000Medicaid
WV001710014OtherWEST VIRGINIA BLUE SHIELD
WV001710014OtherWEST VIRGINIA BLUE SHIELD
WV9248251Medicare PIN