Healthcare Provider Details

I. General information

NPI: 1023458478
Provider Name (Legal Business Name): TYLER J. KELLY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2013
Last Update Date: 12/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 CROSSLAKE DR
EVANSVILLE IN
47715-8198
US

IV. Provider business mailing address

225 CROSSLAKE DR.
EVANSVILLE IN
47715-7607
US

V. Phone/Fax

Practice location:
  • Phone: 812-477-1558
  • Fax:
Mailing address:
  • Phone: 812-477-1558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number41000290A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: