Provider Demographics
NPI:1992242184
Name:KAE KELLY SURGICAL INC
Entity type:Organization
Organization Name:KAE KELLY SURGICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYLVANUS
Authorized Official - Middle Name:
Authorized Official - Last Name:OYOGOA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-598-5707
Mailing Address - Street 1:1038 N. EISENHOWER DR
Mailing Address - Street 2:PMB 286
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801
Mailing Address - Country:US
Mailing Address - Phone:304-253-5690
Mailing Address - Fax:
Practice Address - Street 1:1828 HARPER RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3366
Practice Address - Country:US
Practice Address - Phone:304-253-5690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1801863139OtherNPI