MEDICARE: DR. KELLY S TATE MD

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	207Q00000X	Family Medicine Physician	27148	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700839040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY S TATE MD

Provider Business Mailing Address
First Line	:	118 S MAIN ST
Second Line	:
City	:	ELKTON
State	:	KY
Zip	:	42220-8863
Country	:	US
Telephone Number	:	270-265-5023
Fax Number	:	270-265-5026

Provider Business Practice Location Address
First Line	:	118 S MAIN ST
Second Line	:
City	:	ELKTON
State	:	KY
Zip	:	42220-8863
Country	:	US
Telephone Number	:	270-265-5023
Fax Number	:	270-265-5026

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

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	06/14/2024

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