Provider Demographics
NPI:1811971666
Name:KELLY, BRIAN P (DPT, SCS, ATC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:P
Last Name:KELLY
Suffix:
Gender:M
Credentials:DPT, SCS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5629
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47716-5629
Mailing Address - Country:US
Mailing Address - Phone:812-476-0409
Mailing Address - Fax:812-476-1016
Practice Address - Street 1:415 CROSSLAKE DR STE B
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715
Practice Address - Country:US
Practice Address - Phone:812-476-0409
Practice Address - Fax:812-476-1016
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005037A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200839360Medicaid
IN000000197256OtherBLUE CROSS BLUE SHIELD
IN650022585Medicare UPIN
IN216070IIMedicare PIN
IN000000197256OtherBLUE CROSS BLUE SHIELD