Individual
LAWRENCE BENNETT KELLY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
4825 MACCORKLE AVE SW STE C, SOUTH CHARLESTON, WV 25309-1365
(304) 343-1022
(304) 343-1025
Mailing address
PO BOX 11850, CHARLESTON, WV 25339-1850
(304) 343-1022
(304) 343-1025
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
12306
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001720795
BLUE CROSS BLUE SHIELD
WV
05
—
0114543001
—
WV
01
—
260047649
MEDICARE RAILROAD
WV
Enumeration date
04/08/2006
Last updated
02/02/2024
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