Kelley, Jack Leslie

Kelley, Jack Leslie is an individual health care provider with primary practice located at 1500 Salem St , Lafayette IN 47904-2164. He recently has only one registered license in Allopathic & Osteopathic Physicians / Surgery, which is considered as his primary health care specialty. Kelley, Jack Leslie can be contacted via phone (765) 448-8000.

Contact Information

Primary practice address
1500 Salem St Lafayette IN 47904-2164
Phone: (765) 448-8000
Fax: (765) 448-8337
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Surgery 208600000X 01022437A Indiana

Profile Details

NPI number 1710956065
LBN Legal business name Kelley, Jack Leslie
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 No
Enumeration date Mar 17th, 2006
Last updated Jul 23rd, 2012 - about 14 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1710956065 NPPES
Indiana Other 000000197818 ANTHEM PROVIDER NUMBER
Indiana MEDICAID KE80251002 ANTHEM PROVIDER NUMBER
Indiana MEDICAID 100230510 ANTHEM PROVIDER NUMBER
Indiana Other 10825369 ANTHEM PROVIDER NUMBER
Indiana Other 9017025 ANTHEM PROVIDER NUMBER

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