Provider Demographics
NPI:1851364756
Name:LINICK, KELLI (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:LINICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 BLUE RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24523-2604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:548 BLUE RIDGE AVE
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-2604
Practice Address - Country:US
Practice Address - Phone:540-586-4723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-052921207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005627206Medicaid
VA5637988Medicaid
VA5627214Medicaid
VA018054C18Medicare PIN
080006212Medicare PIN
VA5627214Medicaid
080006211Medicare PIN