Basic Information
| Provider Information | |||||||||
| NPI: | 1598721219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 E MARKET ST | ||||||||
| Address2: | ANNEX 3 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303757512 | ||||||||
| FaxNumber: | 3303753445 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 ARCH ST | ||||||||
| Address2: | SUITE 002 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753584 | ||||||||
| FaxNumber: | 3303756306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34-008328 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2527288 | 05 | OH | MEDICAID |