MEDICARE: KELLY L WADESON PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6019	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000326700	OTHER	OH	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649297557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY L WADESON PHD

Provider Business Mailing Address
First Line	:	250 METROHEALTH DR
Second Line	:	METROHEALTH MEDICAL CENTER
City	:	CLEVELAND
State	:	OH
Zip	:	44109-1998
Country	:	US
Telephone Number	:	216-778-8804
Fax Number	:	216-778-5560

Provider Business Practice Location Address
First Line	:	250 METROHEALTH DR
Second Line	:	METROHEALTH MEDICAL CENTER
City	:	CLEVELAND
State	:	OH
Zip	:	44109-1998
Country	:	US
Telephone Number	:	216-778-8804
Fax Number	:	216-778-5560

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	07/23/2007

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