Provider Demographics
NPI:1992705214
Name:KELLEY, CHARLES G (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:KELLEY
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:PO BOX 3160
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460
Mailing Address - Country:US
Mailing Address - Phone:866-623-3869
Mailing Address - Fax:203-874-5209
Practice Address - Street 1:70 EAST ST
Practice Address - Street 2:CARITAS HOLY FAMILY HOSPITAL
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844
Practice Address - Country:US
Practice Address - Phone:978-687-0151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA34236207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2031337Medicaid
NH00000841OtherWELFARE
MAD19030OtherBCBS
772243OtherTUFT
050034800Medicare ID - Type UnspecifiedRR
D19030Medicare ID - Type Unspecified
772243OtherTUFT
MA050034800Medicare Oscar/Certification