MEDICARE: MR. ERIC KELLEY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	3657671	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134102346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ERIC KELLEY MD

Provider Business Mailing Address
First Line	:	2215 S 17TH AVE
Second Line	:
City	:	BROADVIEW
State	:	IL
Zip	:	60155-4728
Country	:	US
Telephone Number	:	708-344-7171
Fax Number	:	708-344-0319

Provider Business Practice Location Address
First Line	:	2215 17TH AVE
Second Line	:
City	:	BROADVIEW
State	:	IL
Zip	:	60155-4728
Country	:	US
Telephone Number	:	708-344-7171
Fax Number	:	708-344-0319

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	02/10/2010

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Directions to “ MR. ERIC KELLEY MD” Practice Location

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