Provider Demographics
NPI:1609945443
Name:KELLY, GREGORY DENNIS (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:DENNIS
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9202
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:
Practice Address - Street 1:1400 HOSPITAL DR
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9202
Practice Address - Country:US
Practice Address - Phone:304-757-1767
Practice Address - Fax:304-757-1716
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV744207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV000681385OtherBLUE CROSS BLUE SHIELD
WV1052927OtherWV DWC
WV0050063000OtherWV MEDICAID
WV0526148Medicare PIN
WV0050063000OtherWV MEDICAID
WV1052927OtherWV DWC
WV000681385OtherBLUE CROSS BLUE SHIELD
WVP00412371Medicare PIN
WV0526147Medicare PIN