Basic Information
| Provider Information | |||||||||
| NPI: | 1861408932 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 494 | ||||||||
| Address2: | |||||||||
| City: | NASSAU | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199690494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3025690352 | ||||||||
| FaxNumber: | 3026459714 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 JOSEPH SIEWICK DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033913600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 0101054870 | VA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 0101054870 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010113261 | 05 | VA | MEDICAID |