Provider Demographics
NPI:1710956065
Name:KELLEY, JACK LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:LESLIE
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:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:1500 SALEM ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2164
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-8337
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022437A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000197818OtherANTHEM PROVIDER NUMBER
INKE80251002Medicaid
IN100230510Medicaid
IN10825369OtherCAQH NUMBER
IN9017025OtherPHCS PID NUMBER
INE03840Medicare UPIN
IN9017025OtherPHCS PID NUMBER
INKE80251002Medicaid
IN815500BBMedicare PIN