Provider Demographics
NPI:1023055928
Name:ELLEDGE, KAY E (MD)
Entity type:Individual
Prefix:
First Name:KAY
Middle Name:E
Last Name:ELLEDGE
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 1:3701 SKYPARK DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4753
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3701 SKYPARK DR
Practice Address - Street 2:SUITE 150
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4753
Practice Address - Country:US
Practice Address - Phone:310-378-8450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86986207V00000X
WI36123207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1023055928Medicaid