Provider Demographics
NPI:1093247447
Name:KELLY, CHARLES M II (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:KELLY
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C.
Other - Middle Name:MICHAEL
Other - Last Name:KELLY
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1705 N HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:CANNON FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:55009-1187
Mailing Address - Country:US
Mailing Address - Phone:507-263-4900
Mailing Address - Fax:
Practice Address - Street 1:1705 N HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CANNON FALLS
Practice Address - State:MN
Practice Address - Zip Code:55009-1187
Practice Address - Country:US
Practice Address - Phone:507-263-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN67391207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine