=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740385525
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA H KELLY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2006
-----------------------------------------------------
Last Update Date | 07/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7250 CLEARVISTA DR SUITE 327A
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46256-4692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-621-7390
-----------------------------------------------------
Fax | 317-621-4494
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7250 CLEARVISTA DR SUITE 327A
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46256-4692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-621-7390
-----------------------------------------------------
Fax | 317-621-4494
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 01028621A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------