Provider Demographics
NPI:1174608442
Name:KELLY, JAMES PATRICK (MD, MBA)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:PATRICK
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17022 SHANDWICK LANE
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530
Mailing Address - Country:US
Mailing Address - Phone:574-277-9156
Mailing Address - Fax:574-271-5639
Practice Address - Street 1:17022 SHANDWICK LANE
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530
Practice Address - Country:US
Practice Address - Phone:574-277-9156
Practice Address - Fax:574-271-5639
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034778208G00000X
IN1034778A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100193010AMedicaid
IN100193010AMedicaid
B89029Medicare UPIN