Basic Information
| Provider Information | |||||||||
| NPI: | 1609945443 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | DENNIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255269202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1400 HOSPITAL DR | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255269202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047571767 | ||||||||
| FaxNumber: | 3047571716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 01/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 744 | WV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000681385 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER | 1052927 | 01 | WV | WV DWC | OTHER | 0050063000 | 01 | WV | WV MEDICAID | OTHER |