Individual
KELLY J. CASSEDY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
130 W RAVINE RD, KINGSPORT, TN 37660-3810
(423) 968-1144
(423) 968-3453
Mailing address
3053 W STATE ST, BRISTOL, TN 37620-1720
(423) 968-1144
(423) 968-3453
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
23468
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0218543000
—
WV
01
—
300066625
PGBA (RR MEDICARE)
—
01
—
3058511
BCBS
TN
05
—
3070168
—
TN
05
—
64927528
—
KY
05
—
7213425
—
VA
01
—
RO6903
JOHN DEERE
TN
Enumeration date
08/09/2005
Last updated
07/11/2023
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