MEDICARE: KEVIN GERARD KELLY

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	207Q00000X	Family Medicine Physician	8497	AL

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	:	1710972385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN GERARD KELLY

Provider Business Mailing Address
First Line	:	13150 HIGHWAY 43
Second Line	:	SUITE 10
City	:	RUSSELLVILLE
State	:	AL
Zip	:	35653-4558
Country	:	US
Telephone Number	:	256-332-5901
Fax Number	:	256-332-6911

Provider Business Practice Location Address
First Line	:	13150 HIGHWAY 43
Second Line	:	SUITE 10
City	:	RUSSELLVILLE
State	:	AL
Zip	:	35653-4558
Country	:	US
Telephone Number	:	256-332-5901
Fax Number	:	256-332-6911

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

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	03/28/2014

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Directions to “ KEVIN GERARD KELLY ” Practice Location

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