Provider Demographics
NPI:1811170939
Name:KELTY, ANTHONY
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:KELTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 BRECKENRIDGE LN
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2742
Mailing Address - Country:US
Mailing Address - Phone:502-458-7400
Mailing Address - Fax:502-458-7449
Practice Address - Street 1:3101 BRECKENRIDGE LN
Practice Address - Street 2:SUITE 1A
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2742
Practice Address - Country:US
Practice Address - Phone:502-458-7400
Practice Address - Fax:502-458-7449
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1088901367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3503755000OtherPASSPORT ADVANTAGE
KY000000547672OtherBLUE SHIELD
KY7100110180Medicaid
KY50018644OtherPASSPORT
KY000000547672OtherBLUE SHIELD