Provider Demographics
NPI:1023099579
Name:KELLEY, REBECCA B (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:B
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 E HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65240-1183
Mailing Address - Country:US
Mailing Address - Phone:573-582-5588
Mailing Address - Fax:573-682-1539
Practice Address - Street 1:1021 E HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:MO
Practice Address - Zip Code:65240-1183
Practice Address - Country:US
Practice Address - Phone:573-682-5588
Practice Address - Fax:573-682-1539
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208727727Medicaid
263971OtherRURAL HEALTHCARE CLINIC
MO208727727Medicaid
000013718Medicare ID - Type Unspecified