Provider Demographics
NPI:1295947844
Name:LAWRENCE B. KELLY, MD PLLC
Entity type:Organization
Organization Name:LAWRENCE B. KELLY, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:BENNETT
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-343-1022
Mailing Address - Street 1:PO BOX 11850
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339-1850
Mailing Address - Country:US
Mailing Address - Phone:304-343-1022
Mailing Address - Fax:304-343-1025
Practice Address - Street 1:4825 MACCORKLE AVE SW STE C
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1365
Practice Address - Country:US
Practice Address - Phone:304-343-1022
Practice Address - Fax:304-343-1025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810011496Medicaid
WV001720795OtherBLUE CROSS BLUE SHIELD
WVDN1230OtherMEDICARE RAILROAD
WV3810011496Medicaid