Healthcare Provider Details

I. General information

NPI: 1770799124
Provider Name (Legal Business Name): KELLY LEE EVANS-RANKIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY LEE EVANS MD

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 5 MILE RD STE 105
CINCINNATI OH
45230-2187
US

IV. Provider business mailing address

7500 STATE RD
CINCINNATI OH
45255-2439
US

V. Phone/Fax

Practice location:
  • Phone: 513-233-6980
  • Fax: 513-233-6983
Mailing address:
  • Phone: 513-624-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number44125
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number44125
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35.138436
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.138436
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: