Healthcare Provider Details

I. General information

NPI: 1689721474
Provider Name (Legal Business Name): KELLY MELVIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 12/17/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 20TH ST SUITE 205
HUNTINGTON WV
25703-2071
US

IV. Provider business mailing address

1115 20TH ST SUITE 205
HUNTINGTON WV
25703-2071
US

V. Phone/Fax

Practice location:
  • Phone: 304-691-1500
  • Fax: 304-523-4358
Mailing address:
  • Phone: 304-691-1500
  • Fax: 304-523-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number24023
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number24023
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: