Provider Demographics
NPI:1306821178
Name:KELSO, GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:KELSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 BETHESDA DR
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1800
Mailing Address - Country:US
Mailing Address - Phone:740-454-4651
Mailing Address - Fax:740-454-4653
Practice Address - Street 1:860 BETHESDA DR
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-1800
Practice Address - Country:US
Practice Address - Phone:740-454-4651
Practice Address - Fax:740-454-4653
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35082836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2434600Medicaid
KE4115011OtherMEDICARE PTAN
OH000000300315OtherANTHEM PIN
OH311413469036OtherCARESOURCE PIN
OH0949499OtherGROUP MEDICAID
OH0111122OtherUHC PIN
OHP00096768OtherMEDICARE RAILROAD
OH00000017743OtherUNISON PIN
CA1586OtherGROUP MEDICARE RAILROAD
H69694Medicare UPIN
KE4115011Medicare PIN
9270903Medicare PIN