Healthcare Provider Details

I. General information

NPI: 1265135826
Provider Name (Legal Business Name): GAVIN WILLIAM KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE
CLEVELAND OH
44106-1716
US

IV. Provider business mailing address

28115 SOUTHBRIDGE CIR
WESTLAKE OH
44145-5327
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-1000
  • Fax:
Mailing address:
  • Phone: 440-941-2959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35.155567
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: