MEDICARE: KELLY L COLE D.O.

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	207Q00000X	Family Medicine Physician	02437	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00000043968	OTHER	KY	ANTHEM BLUE CROSS & BLUE
2	027299800	OTHER		BLACK LUNG
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	1386132	OTHER		THE FUNDS ID
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588638969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY L COLE D.O.

Provider Business Mailing Address
First Line	:	PO BOX 310
Second Line	:
City	:	PROVIDENCE
State	:	KY
Zip	:	42450-0310
Country	:	US
Telephone Number	:	270-667-2023
Fax Number	:	270-667-7518

Provider Business Practice Location Address
First Line	:	121 E MAIN ST
Second Line	:
City	:	PROVIDENCE
State	:	KY
Zip	:	42450-1268
Country	:	US
Telephone Number	:	270-667-2023
Fax Number	:	270-667-7518

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

Provider Enumeration Date	:	02/14/2006
Last Update Date	:	11/20/2007

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Directions to “ KELLY L COLE D.O.” Practice Location

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