Healthcare Provider Details

I. General information

NPI: 1811142250
Provider Name (Legal Business Name): CHARLES W. KELLEY III D.P.M.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2008
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5602 MADISON AVE
INDIANAPOLIS IN
46227-4625
US

IV. Provider business mailing address

5602 MADISON AVE
INDIANAPOLIS IN
46227-4625
US

V. Phone/Fax

Practice location:
  • Phone: 317-786-2239
  • Fax: 317-784-2055
Mailing address:
  • Phone: 317-786-2239
  • Fax: 317-784-2055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number07000355A
License Number StateIN

VIII. Authorized Official

Name: DR. CHARLES WALTER KELLEY III
Title or Position: SOLE PROPRIETOR
Credential: D.P.M.
Phone: 317-786-2239