Provider Demographics
NPI:1487651766
Name:BANKS, KELLY L (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:BANKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:925 HIGHLAND BLVD
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6900
Mailing Address - Country:US
Mailing Address - Phone:406-414-4550
Mailing Address - Fax:406-414-4599
Practice Address - Street 1:925 HIGHLAND BLVD
Practice Address - Street 2:STE 1200
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6900
Practice Address - Country:US
Practice Address - Phone:406-587-0704
Practice Address - Fax:406-587-1147
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2017-09-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MT6438208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0085748Medicaid
MTE28053Medicare UPIN
MT0085748Medicaid
MT000009823Medicare ID - Type UnspecifiedBANKS INDIVIDUAL ID MEDIC