Provider Demographics
NPI:1104895267
Name:KELLY, CHARLES (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MS
Mailing Address - Zip Code:38843-9001
Mailing Address - Country:US
Mailing Address - Phone:662-862-5200
Mailing Address - Fax:662-862-5297
Practice Address - Street 1:1 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MS
Practice Address - Zip Code:38843-9001
Practice Address - Country:US
Practice Address - Phone:662-862-5200
Practice Address - Fax:662-862-5297
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15058207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117294Medicaid
MS080002503Medicare ID - Type Unspecified
MS00117294Medicaid