Provider Demographics
NPI:1578838660
Name:MONTGOMERY, KELSEY A (DO)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:A
Last Name:MONTGOMERY
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:A
Other - Last Name:DUKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 778912
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8912
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:8111 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8601
Practice Address - Country:US
Practice Address - Phone:317-865-5541
Practice Address - Fax:317-865-5148
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY038392080N0001X
FLOS185632080N0001X
IN02005088A2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300017874Medicaid
IN1578838660Medicaid