Basic Information
| Provider Information | |||||||||
| NPI: | 1992705214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3160 | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666233869 | ||||||||
| FaxNumber: | 2038745209 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 EAST ST | ||||||||
| Address2: | CARITAS HOLY FAMILY HOSPITAL | ||||||||
| City: | METHUEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786870151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 10/26/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 34236 | MA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2031337 | 05 | MA | MEDICAID | 00000841 | 01 | NH | WELFARE | OTHER | D19030 | 01 | MA | BCBS | OTHER | 772243 | 01 | TUFT | OTHER |