Provider Demographics
NPI:1710546213
Name:BASTIAN, KELSEY RAY (MD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:RAY
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:920 MADISON AVENUE SUITE 447
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38163-3438
Mailing Address - Country:US
Mailing Address - Phone:901-448-2302
Mailing Address - Fax:
Practice Address - Street 1:920 MADISON AVE FL 2
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3438
Practice Address - Country:US
Practice Address - Phone:901-448-2302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN00000677612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry