Basic Information
| Provider Information | |||||||||
| NPI: | 1841243292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUMBLEY | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194342 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 W RAVINE RD | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232245109 | ||||||||
| FaxNumber: | 4232245120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | DO1771 | TN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 0102202993 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 34008110 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3319838 | 05 | TN | MEDICAID | 3319837 | 05 | TN | MEDICAID |