Healthcare Provider Details

I. General information

NPI: 1982606315
Provider Name (Legal Business Name): KEVIN J KELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11108 PARKVIEW CIRCLE DR
FORT WAYNE IN
46845-1730
US

IV. Provider business mailing address

3926 NEW VISION DR SUITE 1
FORT WAYNE IN
46845-1712
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-5700
  • Fax: 260-266-5920
Mailing address:
  • Phone: 260-373-9705
  • Fax: 260-373-9705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01032406A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: