Basic Information
| Provider Information | |||||||||
| NPI: | 1457451577 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCHANAN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | V. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 714328 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432714328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003541985 | ||||||||
| FaxNumber: | 4403504938 | ||||||||
| Practice Location | |||||||||
| Address1: | 36001 EUCLID AVE STE C7 | ||||||||
| Address2: | |||||||||
| City: | WILLOUGHBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440944650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406026710 | ||||||||
| FaxNumber: | 4402698107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35077218B | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2225103 | 05 | OH | MEDICAID |