Provider Demographics
NPI:1972543064
Name:KELLEY, KARL DAVID (MD)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:DAVID
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 1:4059 KEITH RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-6971
Mailing Address - Country:US
Mailing Address - Phone:615-384-6222
Mailing Address - Fax:
Practice Address - Street 1:310 N L ROGERS WELLS BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1300
Practice Address - Country:US
Practice Address - Phone:270-659-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38748207P00000X
KY46833207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3897033OtherBLUE CROSS
TN10021964OtherOMNICARE TENNCARE
TN3897036Medicaid
TNP00357334OtherMEDICARE RAILROAD
TNP00241188OtherMEDICARE RAILROAD
TN3809694Medicaid
TN4086997OtherBLUE CROSS
TN4124223OtherBLUE CROSS
KY50007338OtherPASSPORT HEALTH
TN41090OtherTLC TENNCARE
TN4124510OtherBLUE CROSS
KY64086663Medicaid
TN4086997OtherBLUE CROSS
TN38970361Medicare PIN
TN3809694Medicare PIN