Provider Demographics
NPI:1306036975
Name:KELLY, THOMAS JOHN (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:KELLY
Suffix:
Gender:M
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:PO BOX 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-272-5100
Mailing Address - Fax:502-272-5114
Practice Address - Street 1:315 E BROADWAY STE 185-C
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3700
Practice Address - Country:US
Practice Address - Phone:502-629-5455
Practice Address - Fax:502-629-4151
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP216208100000X
PAMT190022208100000X
KY43896208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100129640Medicaid
KY9608821OtherCIGNA - NRP
KY000052153TOtherHUMANA - NRP
IN201016740Medicaid
KYP00948781OtherRAILROAD MEDICARE KENTUCKY
KY000000667398OtherANTHEM - NRP
KY50029614OtherPASSPORT & PASSPORT ADVTG - NRP
KY116470OtherSIHO - NRP
IN201016740Medicaid
INM400020141Medicare PIN