Individual
KEVIN J KELLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
11108 PARKVIEW CIRCLE DR, FORT WAYNE, IN 46845-1730
(260) 266-5700
(260) 266-5920
Mailing address
3926 NEW VISION DR, SUITE 1, FORT WAYNE, IN 46845-1712
(260) 373-9705
(260) 373-9705
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
Primary
01032406A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000641087
ANTHEM
IN
05
—
0522401
—
OH
01
—
060070567
RR MEDICARE
IN
01
—
060071114
RR MEDICARE
OH
01
—
06199
MEDICAID OHIO PARAMONT
OH
05
—
100360760
—
IN
01
—
P00786817
R.R. MEDICARE
IN
01
—
P00846125
MEDICARE RAILROAD
OH
Enumeration date
08/15/2005
Last updated
11/29/2016
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