Provider Demographics
NPI:1558359893
Name:GROSSMAN, KELLY LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LOUIS
Last Name:GROSSMAN
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 1:1263 HOSPITAL DR NW
Mailing Address - Street 2:SUITE 250
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-2172
Mailing Address - Country:US
Mailing Address - Phone:812-738-8136
Mailing Address - Fax:812-738-3155
Practice Address - Street 1:1263 HOSPITAL DR NW
Practice Address - Street 2:SUITE 250
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2172
Practice Address - Country:US
Practice Address - Phone:812-738-8136
Practice Address - Fax:812-738-3155
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048923A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00200004OtherRR MEDICARE
IN000000335255OtherANTHEM
IN200266000Medicaid
H10387Medicare UPIN
INM400017730Medicare PIN