Provider Demographics
NPI:1982606315
Name:KELLY, KEVIN J (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:KELLY
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 1:3926 NEW VISION DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1712
Mailing Address - Country:US
Mailing Address - Phone:260-373-9705
Mailing Address - Fax:260-373-9705
Practice Address - Street 1:11108 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1730
Practice Address - Country:US
Practice Address - Phone:260-266-5700
Practice Address - Fax:260-266-5920
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032406A207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH060071114OtherRR MEDICARE
OH06199OtherMEDICAID OHIO PARAMONT
INP00786817OtherR.R. MEDICARE
OHP00846125OtherMEDICARE RAILROAD
IN000000641087OtherANTHEM
IN100360760Medicaid
OH0522401Medicaid
IN060070567OtherRR MEDICARE
IN193590JMedicare PIN
OHKE0643398Medicare PIN
OHKE0643399Medicare PIN
IN100360760Medicaid
IN060070567Medicare PIN
OHP00846125OtherMEDICARE RAILROAD
OH06199OtherMEDICAID OHIO PARAMONT
IN060070567OtherRR MEDICARE