Healthcare Provider Details

I. General information

NPI: 1912187097
Provider Name (Legal Business Name): KELLY VICTORIA RENNIE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 09/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 WASHINGTON ST E SUITE 208
CHARLESTON WV
25301-1834
US

IV. Provider business mailing address

1201 WASHINGTON ST E SUITE 208
CHARLESTON WV
25301-1834
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-7270
  • Fax:
Mailing address:
  • Phone: 304-388-7270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberPGY.1.TUL-SURG
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number26075
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: