Healthcare Provider Details

I. General information

NPI: 1891772059
Provider Name (Legal Business Name): RONALD L. KELLEY PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 01/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6025 KENTUCKY DAM RD
PADUCAH KY
42003-9472
US

IV. Provider business mailing address

PO BOX 3126
PADUCAH KY
42002-3126
US

V. Phone/Fax

Practice location:
  • Phone: 270-898-4044
  • Fax: 270-898-4045
Mailing address:
  • Phone: 270-898-4044
  • Fax: 270-898-4045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RONALD L. KELLEY
Title or Position: CEO
Credential: M.D.
Phone: 270-898-4044