Basic Information
Provider Information | |||||||||
NPI: | 1124462221 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KELTY | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | PATRICK | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 936 | ||||||||
Address2: |   | ||||||||
City: | LONDON | ||||||||
State: | KY | ||||||||
PostalCode: | 407430936 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6063307835 | ||||||||
FaxNumber: | 6063307825 | ||||||||
Practice Location | |||||||||
Address1: | 3581 HARRODSBURG RD STE 350 | ||||||||
Address2: |   | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405131140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593136333 | ||||||||
FaxNumber: | 8593133484 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2013 | ||||||||
LastUpdateDate: | 03/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 50340 | KY | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | 50340 | KY | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 7100312460 | 05 | KY |   | MEDICAID |