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
State | License ID | Taxonomies |
---|---|---|
TN | 23468 | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TN | 3058511 | Other | BCBS |
VA | 7213425 | Medicaid | |
TN | RO6903 | Other | JOHN DEERE |
TN | 3070168 | Medicaid | |
KY | 64927528 | Medicaid | |
300066625 | Other | PGBA (RR MEDICARE) | |
WV | 0218543000 | Medicaid | |
VA | 7213425 | Medicaid |