Provider Demographics
NPI:1356324370
Name:GAGE, KELLY DAVID (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DAVID
Last Name:GAGE
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:PO BOX 12087
Mailing Address - Street 2:PENNINSULA RADIOLOGICAL ASSOCIATES
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23612-2087
Mailing Address - Country:US
Mailing Address - Phone:757-867-6101
Mailing Address - Fax:757-867-7547
Practice Address - Street 1:618 HOSPITAL ROAD
Practice Address - Street 2:RIVERSIDE TAPPAHANNOCK HOSPITAL
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-5000
Practice Address - Country:US
Practice Address - Phone:804-443-6044
Practice Address - Fax:757-867-7547
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01053434A2085R0202X
VA01012426652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1356324370Medicaid
VAP00447500Medicare PIN