Basic Information
| Provider Information | |||||||||
| NPI: | 1265570469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELSO | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 902 N HOWE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284613038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104574789 | ||||||||
| FaxNumber: | 9105794589 | ||||||||
| Practice Location | |||||||||
| Address1: | 902 N HOWE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284613038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104574789 | ||||||||
| FaxNumber: | 9105794589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 12/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 120032 | MO | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 200300626 | NC | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 204883003 | 05 | MO | MEDICAID |