Basic Information
| Provider Information | |||||||||
| NPI: | 1013969401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIEVES | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Practice Location | |||||||||
| Address1: | 9911 N NEVADA ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992181298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096269420 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| 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 | 207Q00000X | MD60529250 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35093040 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000278783 | 01 | OH | OHIO MEDICAID - UNISON | OTHER | 2984105 | 01 | OH | OHIO MEDICAID MOLINA | OTHER | 2878444 | 05 | OH | MEDICAID | P00766489 | 01 | RR MEDICARE | OTHER | 1013969401214 | 01 | OH | OHIO MEDICAID - CARESOURCE | OTHER | 3810015770 | 05 | WV | MEDICAID |