Basic Information
| Provider Information | |||||||||
| NPI: | 1902928799 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELSO | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043165100 | ||||||||
| FaxNumber: | 7043165101 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 QUEENS RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043165100 | ||||||||
| FaxNumber: | 7043165101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A82292 | CA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 2018-00611 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 094030 | OH | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 2018-00611 | NC | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.