Provider Demographics
NPI:1144437740
Name:JON A KELLY DPM
Entity type:Organization
Organization Name:JON A KELLY DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:412-673-9222
Mailing Address - Street 1:1601 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:WHITE OAK
Mailing Address - State:PA
Mailing Address - Zip Code:15131-1720
Mailing Address - Country:US
Mailing Address - Phone:412-673-9222
Mailing Address - Fax:412-673-0022
Practice Address - Street 1:1601 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:WHITE OAK
Practice Address - State:PA
Practice Address - Zip Code:15131-1720
Practice Address - Country:US
Practice Address - Phone:412-673-9222
Practice Address - Fax:412-673-0022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003063L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010971010011Medicaid
PA1396761268OtherINDIVIDUAL NPI
PA602340OtherHIGHMARK GROUP NUMBER
PA602340OtherHIGHMARK GROUP NUMBER
PA1396761268OtherINDIVIDUAL NPI
PA069369Medicare ID - Type UnspecifiedGROUP PROVIDER