Active NPI
Kelly R Pettit, MD
- Emergency Medicine Physician
- Redmond, OR
National Provider Identifier
1659454544
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Emergency Medicine Physician
- License
- MD2006-0194
- Practice address
- 1253 NW Canal Blvd
Redmond, OR 97756-1334 - Phone
- (541) 548-8131
- Fax
- (541) 526-6608
- NPI assigned
- Oct 23, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Emergency Medicine Physician | 207P00000X | MD2006-0194 | NM | Primary |
Addresses
Primary practice location
1253 NW Canal Blvd
Redmond, OR 97756-1334
Mailing address
275 E 200 S
Salt Lake City, UT 84111-2002
Phone (800) 366-1884
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MD2006-0194 | NM | MD | Emergency Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Public Hospital District No 1 of Mason County | Past | Accepting new patients |
Interoperability endpoints
- kpettit18225@secure.stcharleshealthcare.org
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Critical Access Hospital
- Shelton, WA
- NPI 1760568752
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1161561600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1656633600000",
"number": "1659454544",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "275 E 200 S",
"city": "SALT LAKE CITY",
"state": "UT",
"postal_code": "841112002",
"telephone_number": "800-366-1884"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1253 NW CANAL BLVD",
"city": "REDMOND",
"state": "OR",
"postal_code": "977561334",
"telephone_number": "541-548-8131",
"fax_number": "541-526-6608"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETTIT",
"first_name": "KELLY",
"middle_name": "R",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-10-23",
"last_updated": "2022-07-01",
"certification_date": "2022-07-01",
"status": "A"
},
"taxonomies": [
{
"code": "207P00000X",
"taxonomy_group": "",
"desc": "Emergency Medicine",
"state": "NM",
"license": "MD2006-0194",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Redmond, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 1, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.