Basic Information
| Provider Information | |||||||||
| NPI: | 1053375170 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDERHAVE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601372 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043555982 | ||||||||
| FaxNumber: | 7043555984 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 MOREHEAD MEDICAL DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043555982 | ||||||||
| FaxNumber: | 7043555984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 2012-02054 | NC | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 4301069717 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 2012-02054 | NC | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1053375170 | 05 | NC | MEDICAID | 5922062 | 05 | NC | MEDICAID | NC1738 | 05 | SC | MEDICAID |