Provider Demographics
NPI:1972576098
Name:KELLY, CHARLES JUDE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JUDE
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 1:20 MEDICAL VILLAGE DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5401
Mailing Address - Country:US
Mailing Address - Phone:859-341-1011
Mailing Address - Fax:859-341-7198
Practice Address - Street 1:20 MEDICAL VILLAGE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5401
Practice Address - Country:US
Practice Address - Phone:859-341-1011
Practice Address - Fax:859-341-7198
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34229208000000X
OH35 07 8628208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
7499170002OtherCIGNA
1202784OtherUNITED HEALTH CARE OF OHI
2501317OtherAETNA
000000175988OtherANTHEM
KY64013543Medicaid
H29301Medicare UPIN