MEDICARE: KELLY L BURROUGH NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	71000164A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P01227319	OTHER	IN	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000542085	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1144276890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY L BURROUGH NP

Provider Business Mailing Address
First Line	:	6626 E 75TH ST
Second Line	:	SUITE 500
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-2890
Country	:	US
Telephone Number	:	317-621-3684
Fax Number	:	317-257-3689

Provider Business Practice Location Address
First Line	:	1095 BROAD RIPPLE AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-2034
Country	:	US
Telephone Number	:	317-621-3731
Fax Number	:	317-621-4037

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	11/27/2023

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Directions to “ KELLY L BURROUGH NP” Practice Location

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