Provider Demographics
NPI:1811142250
Name:CHARLES W. KELLEY III D.P.M.
Entity type:Organization
Organization Name:CHARLES W. KELLEY III D.P.M.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:III
Authorized Official - Credentials:DPM
Authorized Official - Phone:317-786-2239
Mailing Address - Street 1:5602 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-4625
Mailing Address - Country:US
Mailing Address - Phone:317-786-2239
Mailing Address - Fax:317-784-2055
Practice Address - Street 1:5602 MADISON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-4625
Practice Address - Country:US
Practice Address - Phone:317-786-2239
Practice Address - Fax:317-784-2055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000355A213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0146750001Medicare NSC
INT34505Medicare UPIN