Provider Demographics
NPI:1780678979
Name:KELLY, CHARLES E II (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:KELLY
Suffix:II
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 1:2839 HWY 231 NORTH
Mailing Address - Street 2:SUITE 208A
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-7449
Mailing Address - Country:US
Mailing Address - Phone:931-685-8783
Mailing Address - Fax:931-685-8784
Practice Address - Street 1:2839 HWY 231 NORTH
Practice Address - Street 2:SUITE 208A
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-7449
Practice Address - Country:US
Practice Address - Phone:931-685-8783
Practice Address - Fax:931-685-8784
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40151174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3334724Medicaid
TN3334724Medicaid
F14963Medicare UPIN