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General NPI Number Information
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NPI Number | 1730123639
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Entity Type | Individual
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Provider Name | CHARLES E KELLY MD
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Gender | Male
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Dates
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Enumeration Date | 06/15/2006
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Last Update Date | 02/11/2016
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Provider Practice Location Address
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Address Line | 3050 CENTRE POINTE DRIVE SUITE 200
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City | ROSEVILLE
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State | MN
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Zip | 55113
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Country | US
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Telephone | 651-631-4242
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Fax | 651-631-4260
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Provider Business Mailing Address
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Address Line | 3050 CENTRE POINTE DRIVE SUITE 200
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City | ROSEVILLE
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State | MN
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Zip | 55113
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Country | US
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Telephone | 651-639-9150
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Fax | 651-639-9153
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 26263
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 26263
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License Number State | MN
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