Provider Demographics
NPI:1043299589
Name:HALL, KELLI G (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:G
Last Name:HALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E LIBERTY ST
Mailing Address - Street 2:SUITE 801
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1530
Mailing Address - Country:US
Mailing Address - Phone:502-587-9596
Mailing Address - Fax:502-585-2831
Practice Address - Street 1:1850 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4990
Practice Address - Country:US
Practice Address - Phone:812-944-7701
Practice Address - Fax:812-949-5473
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040811208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100381510BMedicaid
IN215250AMedicare ID - Type Unspecified
INE10092Medicare UPIN