Provider Demographics
NPI:1629031901
Name:KELLY, LAWRENCE BENNETT (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:BENNETT
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11850
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339-1850
Mailing Address - Country:US
Mailing Address - Phone:304-343-1022
Mailing Address - Fax:304-343-1025
Practice Address - Street 1:4825 MACCORKLE AVE SW STE C
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1365
Practice Address - Country:US
Practice Address - Phone:304-343-1022
Practice Address - Fax:304-343-1025
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12306174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001720795OtherBLUE CROSS BLUE SHIELD
WV0114543001Medicaid
WV260047649OtherMEDICARE RAILROAD
WV001720795OtherBLUE CROSS BLUE SHIELD
WV0114543001Medicaid