Provider Demographics
NPI:1528009800
Name:KELLY, CHARLES MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C.
Other - Middle Name:MICHAEL
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:17030 LAKESIDE HILLS PLZ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2396
Mailing Address - Country:US
Mailing Address - Phone:402-399-8550
Mailing Address - Fax:402-399-8455
Practice Address - Street 1:7710 MERCY RD
Practice Address - Street 2:SUITE 224
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2372
Practice Address - Country:US
Practice Address - Phone:402-399-8550
Practice Address - Fax:402-399-8455
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16976207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE03880OtherBCBS OF NEBRASKA
NE09-00180OtherSHARE ADVANTAGE/MERCY RD
IA0989095Medicaid
NE47063010113Medicaid
NE16404OtherMIDLANDS CHOICE
NE09-01137OtherSHARE ADVANTAGE/LAKESIDE
NE010033336Medicare PIN
NE09-01137OtherSHARE ADVANTAGE/LAKESIDE
IA0989095Medicaid