MEDICARE: DR. KELLEY KATHLEEN STALEY M.D.

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	208000000X	Pediatrics Physician	036115572	IL

General Provider Information

NPI Number	:	1184652984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLEY KATHLEEN STALEY M.D.

Provider Business Mailing Address
First Line	:	1126 WISCONSIN AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60304-1820
Country	:	US
Telephone Number	:	312-217-1662
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 W SUPERIOR ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-5646
Country	:	US
Telephone Number	:	312-666-3494
Fax Number	:

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	08/09/2021

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