Provider Demographics
NPI:1619188919
Name:KELLEY, TODD C (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:C
Last Name:KELLEY
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 1:4460 RED BANK RD STE 110
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-2173
Mailing Address - Country:US
Mailing Address - Phone:513-791-5200
Mailing Address - Fax:513-791-4229
Practice Address - Street 1:4460 RED BANK RD STE 110
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45227-2173
Practice Address - Country:US
Practice Address - Phone:513-791-5200
Practice Address - Fax:513-791-5229
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-095612207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201001710Medicaid
OH3091014Medicaid
KY7100124750Medicaid
KY7100124750Medicaid