Provider Demographics
NPI:1396856746
Name:KELLY, KEITH EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:EDWARD
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1920 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-7106
Mailing Address - Country:US
Mailing Address - Phone:270-442-3647
Mailing Address - Fax:270-442-3777
Practice Address - Street 1:1920 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7106
Practice Address - Country:US
Practice Address - Phone:270-442-3647
Practice Address - Fax:270-442-3777
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39808207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00266587OtherRAILROAD MEDICARE
KY64113657Medicaid
F97234Medicare UPIN
KY0683704Medicare ID - Type Unspecified