Individual
JACK LESLIE KELLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1500 SALEM ST, LAFAYETTE, IN 47904-2164
(765) 448-8000
(765) 448-8337
Mailing address
PO BOX 5545, LAFAYETTE, IN 47903-5545
(765) 448-8000
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
01022437A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000197818
ANTHEM PROVIDER NUMBER
IN
05
—
100230510
—
IN
01
—
10825369
CAQH NUMBER
IN
01
—
9017025
PHCS PID NUMBER
IN
05
—
KE80251002
—
IN
Enumeration date
03/17/2006
Last updated
07/23/2012
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