=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982606315
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN J KELLY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2005
-----------------------------------------------------
Last Update Date | 11/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11108 PARKVIEW CIRCLE DR
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845-1730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-266-5700
-----------------------------------------------------
Fax | 260-266-5920
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3926 NEW VISION DR SUITE 1
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-373-9705
-----------------------------------------------------
Fax | 260-373-9705
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 01032406A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------