Provider Demographics
NPI:1336157676
Name:SMITH, KELLEY R (DO)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1462
Mailing Address - Country:US
Mailing Address - Phone:814-375-4000
Mailing Address - Fax:814-375-4011
Practice Address - Street 1:100 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1440
Practice Address - Country:US
Practice Address - Phone:724-825-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012962208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0000246632503OtherUNITED HEALTHCARE
PA1539932Medicaid
PA410311OtherUPMC FOR LIFE
PAI13444OtherHEALTHASSURANCE
PAI13444OtherADVANTRA
PA1011784180001Medicaid
PA7364643OtherAETNA
PA14928Medicaid
PASM1641016OtherSECURITY BLUE
PAI13444OtherHEALTHAMERICA
PA158522Medicaid
PA5235361OtherCIGNA
PASM1641016OtherHIGHMARK
PAI13444OtherADVANTRA
PA158522Medicaid
PA1539932Medicaid