Provider Demographics
NPI:1700980265
Name:KELLEY, MICHAEL D (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:KELLEY
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:PO BOX 3407
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47733-3407
Mailing Address - Country:US
Mailing Address - Phone:812-450-6815
Mailing Address - Fax:812-450-6822
Practice Address - Street 1:600 MARY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47747-0001
Practice Address - Country:US
Practice Address - Phone:812-450-3405
Practice Address - Fax:812-450-3099
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054744A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000381080OtherBCBS - GATEWAY
IN076673OtherHAMP #
IN7127259OtherAETNA #
IN000000212792OtherBCBS - MARY STREET
IN200353450Medicaid
IN1973034OtherFIRST HEALTH #
IN470324OtherHEALTHLINK #
KY64036205Medicaid
IN534980BBMedicare ID - Type Unspecified
KY64036205Medicaid
IN7127259OtherAETNA #