MEDICARE: DR. KELLY WITHERS WEST M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	65515	GA
2	208000000X	Pediatrics Physician	125050671	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	65515	OTHER	GA	GEORGIA

General Provider Information

NPI Number	:	1548426323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY WITHERS WEST M.D.

Provider Business Mailing Address
First Line	:	1100 LAKE HEARN DR STE 100
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-1524
Country	:	US
Telephone Number	:	404-256-9809
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 LAKE HEARN DR STE 100
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-1524
Country	:	US
Telephone Number	:	404-256-9809
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2008
Last Update Date	:	12/10/2024

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Directions to “ DR. KELLY WITHERS WEST M.D.” Practice Location

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