Provider Demographics
NPI:1871554212
Name:KELEMEN, JOHN J III (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:KELEMEN
Suffix:III
Gender:M
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:PO BOX 21964
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4116
Mailing Address - Country:US
Mailing Address - Phone:708-342-6900
Mailing Address - Fax:
Practice Address - Street 1:25 HOSPITAL CENTER BLVD STE 306
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926-2739
Practice Address - Country:US
Practice Address - Phone:843-689-8224
Practice Address - Fax:843-689-8360
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-31210208G00000X
WI34064208G00000X
IN01075452A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200326510AMedicaid
KS200326510DMedicaid
IN201291370Medicaid
IN000001006309OtherANTHEM PROVIDER NUMBER
WIK400125638Medicare PIN
KS200326510AMedicaid
IN815500138Medicare PIN
IN201291370Medicaid
KSI28581Medicare UPIN