Provider Demographics
NPI:1518075712
Name:KENLY MEDICAL ASSOCIATES, PA
Entity Type:Organization
Organization Name:KENLY MEDICAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HAL
Authorized Official - Middle Name:B
Authorized Official - Last Name:WOODALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-284-4025
Mailing Address - Street 1:101 E 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:KENLY
Mailing Address - State:NC
Mailing Address - Zip Code:27542-0275
Mailing Address - Country:US
Mailing Address - Phone:919-284-4025
Mailing Address - Fax:919-284-5965
Practice Address - Street 1:101 EAST SECOND STREET
Practice Address - Street 2:
Practice Address - City:KENLY
Practice Address - State:NC
Practice Address - Zip Code:27542-0275
Practice Address - Country:US
Practice Address - Phone:919-284-4025
Practice Address - Fax:919-284-5965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890155KMedicaid
0155KOtherBC
NC2310091Medicare PIN