Provider Demographics
NPI:1710278957
Name:BIRCHENOUGH, KELLY ROSE (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ROSE
Last Name:BIRCHENOUGH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ROSE
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:7785 N STATE ST STE 210
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367-1297
Mailing Address - Country:US
Mailing Address - Phone:315-376-5475
Mailing Address - Fax:315-376-5129
Practice Address - Street 1:7785 N STATE ST STE 210
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367-1297
Practice Address - Country:US
Practice Address - Phone:315-376-5475
Practice Address - Fax:315-376-5129
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS017606207V00000X
NY63054390200000X
NY298638207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program