Healthcare Provider Details

I. General information

NPI: 1619193869
Provider Name (Legal Business Name): KELLY ANN WOOD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY ANN DAVIDSON M.D.

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 COLUMBIA CTR
COLUMBIA IL
62236-2540
US

IV. Provider business mailing address

420 COLUMBIA CTR
COLUMBIA IL
62236-2540
US

V. Phone/Fax

Practice location:
  • Phone: 618-791-2011
  • Fax: 618-417-6046
Mailing address:
  • Phone: 618-719-2011
  • Fax: 618-417-6046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number146940
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number89988457
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036123456
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: