Provider Demographics
NPI:1518960681
Name:BUTLER, KELLY J (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:BUTLER
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 1:10513 CHAMPIONSHIP CT
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-8581
Mailing Address - Country:US
Mailing Address - Phone:502-439-1481
Mailing Address - Fax:
Practice Address - Street 1:101 CABARRUS AVE E
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-3699
Practice Address - Country:US
Practice Address - Phone:888-849-7379
Practice Address - Fax:855-857-7333
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053711A2084P0800X
KY346512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
50704000OtherMAGELLAN MIS GROUP
INCG3623OtherRAILROAD MEDICARE GROUP
000000056294OtherANTHEM GROUP
IN160780OtherMEDICARE GROUP
KYP00289124OtherMEDICARE RAILROAD
IN100386460OtherMEDICAID GROUP
KY2444451000OtherPASSPORT GROUP
KY82900176Medicaid
1063415297OtherGROUP NPI #
KY64029762Medicaid
KY78903689Medicaid
000000239719OtherANTHEM
IN260047968OtherMEDICARE RAILROAD
KY2709741000OtherPASSPORT ADVANTAGE
IN200319860AMedicaid
KY2709741000OtherPASSPORT
KY6764OtherMEDICARE GROUP
264003000OtherMAGELLAN MIS #
KY65927857Medicaid
KYCK2274OtherRAILROAD MEDICARE GROUP
KY2444451000OtherPASSPORT GROUP
IN160780JMedicare ID - Type Unspecified
KY0676412Medicare ID - Type Unspecified