Provider Demographics
NPI:1700839040
Name:TATE, KELLY S (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:S
Last Name:TATE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:KY
Mailing Address - Zip Code:42220-8863
Mailing Address - Country:US
Mailing Address - Phone:270-265-5023
Mailing Address - Fax:270-265-5026
Practice Address - Street 1:118 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:KY
Practice Address - Zip Code:42220-8863
Practice Address - Country:US
Practice Address - Phone:270-265-5023
Practice Address - Fax:270-265-5026
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64271489Medicaid
KYB08640Medicare UPIN
KY1509701Medicare ID - Type Unspecified