Provider Demographics
NPI:1346275583
Name:KRIES, KELLY E (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:KRIES
Suffix:
Gender:F
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:PO BOX 9880
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-9880
Mailing Address - Country:US
Mailing Address - Phone:270-846-4800
Mailing Address - Fax:270-846-4828
Practice Address - Street 1:615 7TH AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101
Practice Address - Country:US
Practice Address - Phone:270-846-4800
Practice Address - Fax:270-846-4828
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36146208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1869901Medicaid
KY1869901Medicaid