Provider Demographics
NPI:1659365674
Name:RISING, KELLY W (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:W
Last Name:RISING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:755 N 11TH ST
Mailing Address - Street 2:SUITE P4200
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1501
Mailing Address - Country:US
Mailing Address - Phone:409-899-1499
Mailing Address - Fax:409-899-1354
Practice Address - Street 1:755 N 11TH ST
Practice Address - Street 2:SUITE P4200
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1501
Practice Address - Country:US
Practice Address - Phone:409-899-1499
Practice Address - Fax:409-899-1354
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2008-05-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXJ1129207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124919502Medicaid
TX160036971OtherRAILROAD MEDICARE
TX124919502Medicaid
F83507Medicare UPIN
TX81Y846Medicare PIN