Provider Demographics
NPI:1144481466
Name:PARK, KELLIE ADRIENNE (MD)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:ADRIENNE
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W TIPTON ST
Mailing Address - Street 2:ATTN: ANESTHESIA DEPT
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2363
Mailing Address - Country:US
Mailing Address - Phone:812-524-2738
Mailing Address - Fax:
Practice Address - Street 1:411 W TIPTON ST
Practice Address - Street 2:ATTN: ANESTHESIA DEPT
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2363
Practice Address - Country:US
Practice Address - Phone:812-524-2738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073835A207L00000X, 207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program