1053513994 NPI number — KELLY MATTHEWS MCCAIN M.S.

Table of content: KELLY MATTHEWS MCCAIN M.S. (NPI 1053513994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053513994 NPI number — KELLY MATTHEWS MCCAIN M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCAIN
Provider First Name:
KELLY
Provider Middle Name:
MATTHEWS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATTHEWS
Provider Other First Name:
KELLY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053513994
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8790 N ASPEN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCCORDSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46055-9398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-557-9690
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 N MERIDIAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46204-3021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-232-0881
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  23002363A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)