Provider Demographics
NPI:1811972128
Name:KELLY, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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 1:406 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1340
Mailing Address - Country:US
Mailing Address - Phone:812-885-2750
Mailing Address - Fax:812-885-2756
Practice Address - Street 1:406 N 1ST ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1340
Practice Address - Country:US
Practice Address - Phone:812-885-2750
Practice Address - Fax:812-885-2756
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029257207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000668746OtherANTHEM
IN100427270Medicaid
INP00851313OtherRAILROAD MEDICARE
INM400018771OtherMEDICARE
IN100427270Medicaid