MEDICARE: DR. AMY MARIE KELLY 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	2080A0000X	Pediatric Adolescent Medicine Physician	40727	MN

General Provider Information

NPI Number	:	1588645121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMY MARIE KELLY M.D.

Provider Business Mailing Address
First Line	:	2247 SARGENT AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1157
Country	:	US
Telephone Number	:	651-699-9555
Fax Number	:

Provider Business Practice Location Address
First Line	:	2004 RANDOLPH AVE
Second Line	:	#4112
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1750
Country	:	US
Telephone Number	:	651-690-6714
Fax Number	:	651-690-6188

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

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	07/08/2007

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