MEDICARE: KELLY VAUGHN-WHITLEY 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	207RC0000X	Cardiovascular Disease Physician	17679	NE
2	207RC0000X	Cardiovascular Disease Physician	3531	SD

General Provider Information

NPI Number	:	1760596928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY VAUGHN-WHITLEY M.D.

Provider Business Mailing Address
First Line	:	PO BOX 706
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57709-0706
Country	:	US
Telephone Number	:	605-341-1300
Fax Number	:	605-341-8785

Provider Business Practice Location Address
First Line	:	13975 NECK YOKE RD
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-7314
Country	:	US
Telephone Number	:	605-341-1300
Fax Number	:	605-341-8785

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

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	06/21/2021

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