Provider Demographics
NPI:1053375170
Name:VANDERHAVE, KELLY LYNN (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:VANDERHAVE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-355-5982
Mailing Address - Fax:704-355-5984
Practice Address - Street 1:1025 MOREHEAD MEDICAL DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2966
Practice Address - Country:US
Practice Address - Phone:704-355-5982
Practice Address - Fax:704-355-5984
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-02054207XX0005X, 207X00000X
MI4301069717207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5922062Medicaid
NC1053375170Medicaid
SCNC1738Medicaid
NC1053375170Medicaid
NC5922062Medicaid