Provider Demographics
NPI:1396761268
Name:KELLY, JON A (DPM)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:A
Last Name:KELLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:MCKEESPORT
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:MCKEESPORT
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-003063-L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010971010011Medicaid
PA602340OtherHIGHMARK BCBS
PA5356590001Medicare NSC
PAT29509Medicare UPIN
PA069369Medicare ID - Type Unspecified