MEDICARE: KELLY DISTEFANO 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	207L00000X	Anesthesiology Physician	MA08068600	NJ

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679511000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY DISTEFANO M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1849
Second Line	:
City	:	LEWISTON
State	:	ME
Zip	:	04241-1849
Country	:	US
Telephone Number	:	207-784-2554
Fax Number	:	207-777-1439

Provider Business Practice Location Address
First Line	:	619 RIVER DR
Second Line	:
City	:	ELMWOOD PARK
State	:	NJ
Zip	:	07407-1317
Country	:	US
Telephone Number	:	201-703-2900
Fax Number	:

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

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	07/24/2018

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