Basic Information
| Provider Information | |||||||||
| NPI: | 1124287917 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARRY | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182130478 | ||||||||
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| Practice Location | |||||||||
| Address1: | 35 EMPIRE STATE BLVD | ||||||||
| Address2: | |||||||||
| City: | CASTLETON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120339777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184772167 | ||||||||
| FaxNumber: | 5184775182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2008 | ||||||||
| LastUpdateDate: | 11/22/2016 | ||||||||
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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 | 207R00000X | 256319 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 256319 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | J400023222 | 05 | NY | MEDICAID |