Provider Demographics
NPI:1609146240
Name:KELLY R WHALEY
Entity Type:Organization
Organization Name:KELLY R WHALEY
Other - Org Name:DR KELLY R WHALEY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:RADER
Authorized Official - Last Name:WHALEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:216-229-0292
Mailing Address - Street 1:PO BOX 182
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-0182
Mailing Address - Country:US
Mailing Address - Phone:216-229-0292
Mailing Address - Fax:440-975-1963
Practice Address - Street 1:144 LARIMAR DR
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-5212
Practice Address - Country:US
Practice Address - Phone:216-229-0292
Practice Address - Fax:440-975-1963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003068213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty