Basic Information
| Provider Information | |||||||||
| NPI: | 1144200346 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | PATRICIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 MEDICAL CENTER DRIVE | ||||||||
| Address2: | SUITE 1300 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911300 | ||||||||
| FaxNumber: | 3046911375 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 MEDICAL CENTER DRIVE | ||||||||
| Address2: | SUITE 3500 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911300 | ||||||||
| FaxNumber: | 3046911375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 11577 | WV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000000178437 | 01 | WV | ANTHEM | OTHER | 001709560 | 01 | WV | MT. STATE | OTHER | 0525293 | 05 | OH | MEDICAID | 64695224 | 05 | KY | MEDICAID |