Provider Demographics
NPI:1639170178
Name:CASSEDY, KELLY J (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:CASSEDY
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 1:3053 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1720
Mailing Address - Country:US
Mailing Address - Phone:423-968-1144
Mailing Address - Fax:423-968-3453
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3810
Practice Address - Country:US
Practice Address - Phone:423-968-1144
Practice Address - Fax:423-968-3453
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN234682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3058511OtherBCBS
VA7213425Medicaid
TNRO6903OtherJOHN DEERE
TN3070168Medicaid
KY64927528Medicaid
300066625OtherPGBA (RR MEDICARE)
WV0218543000Medicaid
VA7213425Medicaid