Basic Information
| Provider Information | |||||||||
| NPI: | 1407855315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2845 CHANCELLOR DR | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593413412 | ||||||||
| FaxNumber: | 8593413171 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 MEDICAL CIR | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067805500 | ||||||||
| FaxNumber: | 6067837281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 04/02/2019 | ||||||||
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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 | 208VP0014X | 27953 | KY | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 2084N0400X | 27953 | KY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 64865728 | 05 | KY | MEDICAID |