Healthcare Provider Details

I. General information

NPI: 1497861819
Provider Name (Legal Business Name): BENWOOD MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 EOFF ST
BENWOOD WV
26031-1008
US

IV. Provider business mailing address

4850 EOFF ST
BENWOOD WV
26031-1008
US

V. Phone/Fax

Practice location:
  • Phone: 304-233-1656
  • Fax: 304-233-1667
Mailing address:
  • Phone: 304-233-1656
  • Fax: 304-233-1667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. LAWRENCE CHARLES KELLY
Title or Position: PRESIDENT OWNER
Credential: DO
Phone: 304-233-1656