Healthcare Provider Details

I. General information

NPI: 1023099579
Provider Name (Legal Business Name): REBECCA B KELLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 E HIGHWAY 22
CENTRALIA MO
65240-1183
US

IV. Provider business mailing address

1021 E HIGHWAY 22
CENTRALIA MO
65240-1183
US

V. Phone/Fax

Practice location:
  • Phone: 573-682-5588
  • Fax: 573-682-1539
Mailing address:
  • Phone: 573-582-5588
  • Fax: 573-682-1539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number106418
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: