Provider Demographics
NPI:1730297748
Name:KELLY, TIMOTHY JOSEPH (MD)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:KELLY
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 1:6626 E 75TH STREET
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7165 CLEARVISTA WAY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4621
Practice Address - Country:US
Practice Address - Phone:317-621-5100
Practice Address - Fax:317-621-7896
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028972207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000872285OtherANTHEM
IN000000078852OtherANTHEM
IN100333150Medicaid
IN000000871759OtherANTHEM
IN000000871726OtherANTHEM
IN000000872285OtherANTHEM
IN000000078852OtherANTHEM
IN000000871759OtherANTHEM
IN266180351Medicare PIN
IN176780Medicare ID - Type Unspecified