Provider Demographics
NPI:1841723582
Name:KELLY, SHAYNE (DO)
Entity type:Individual
Prefix:
First Name:SHAYNE
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:225 CROSSLAKE DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-8198
Mailing Address - Country:US
Mailing Address - Phone:812-477-1558
Mailing Address - Fax:
Practice Address - Street 1:225 CROSSLAKE DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-8198
Practice Address - Country:US
Practice Address - Phone:812-477-1558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02007338A207X00000X
MO2022025432207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery