MEDICARE: KRISTIN NICOLE KELLIM M.P.T.

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	174400000X	Specialist	2008010372	MO
2	225100000X	Physical Therapist	070.017045	IL

General Provider Information

NPI Number	:	1306010913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN NICOLE KELLIM M.P.T.

Provider Business Mailing Address
First Line	:	15 APEX DR
Second Line	:
City	:	HIGHLAND
State	:	IL
Zip	:	62249-1282
Country	:	US
Telephone Number	:	618-651-0444
Fax Number	:	618-654-5439

Provider Business Practice Location Address
First Line	:	1138 VAUGHN RD
Second Line	:
City	:	WOOD RIVER
State	:	IL
Zip	:	62095
Country	:	US
Telephone Number	:	618-259-1100
Fax Number	:	618-259-1101

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

Provider Enumeration Date	:	04/15/2008
Last Update Date	:	02/18/2013

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