Active NPI
Jack Leslie Kelley, MD
- Surgery Physician
- Lafayette, IN
National Provider Identifier
1710956065
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Surgery Physician
- License
- 01022437A
- Practice address
- 1500 Salem St
Lafayette, IN 47904-2164 - Phone
- (765) 448-8000
- Fax
- (765) 448-8337
- NPI assigned
- Mar 17, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Surgery Physician | 208600000X | 01022437A | IN | Primary |
Addresses
Primary practice location
1500 Salem St
Lafayette, IN 47904-2164
Mailing address
PO Box 5545
Lafayette, IN 47903-5545
Phone (765) 448-8000
Other identifiers 5
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 000000197818 | Other | IN | ANTHEM PROVIDER NUMBER |
| KE80251002 | Medicaid | IN | |
| 100230510 | Medicaid | IN | |
| 10825369 | Other | IN | CAQH NUMBER |
| 9017025 | Other | IN | PHCS PID NUMBER |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 01022437A | IN | MD | Surgery Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Riggs Community Health Center Inc | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Federally Qualified Health Center (FQHC)
- Lafayette, IN
- NPI 1386660900
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1142553600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1343001600000",
"number": "1710956065",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 5545",
"city": "LAFAYETTE",
"state": "IN",
"postal_code": "479035545",
"telephone_number": "765-448-8000"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1500 SALEM ST",
"city": "LAFAYETTE",
"state": "IN",
"postal_code": "479042164",
"telephone_number": "765-448-8000",
"fax_number": "765-448-8337"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KELLEY",
"first_name": "JACK",
"middle_name": "LESLIE",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-03-17",
"last_updated": "2012-07-23",
"status": "A"
},
"taxonomies": [
{
"code": "208600000X",
"taxonomy_group": "",
"desc": "Surgery",
"state": "IN",
"license": "01022437A",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "ANTHEM PROVIDER NUMBER",
"identifier": "000000197818",
"state": "IN"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "KE80251002",
"state": "IN"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "100230510",
"state": "IN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "CAQH NUMBER",
"identifier": "10825369",
"state": "IN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PHCS PID NUMBER",
"identifier": "9017025",
"state": "IN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Lafayette, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 23, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.