Healthcare Provider Details

I. General information

NPI: 1154677508
Provider Name (Legal Business Name): SEAN THOMAS KELLY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 MEDICAL CENTER PT
COLORADO SPRINGS CO
80907
US

IV. Provider business mailing address

2 S CASCADE AVE STE 140
COLORADO SPRINGS CO
80903-1604
US

V. Phone/Fax

Practice location:
  • Phone: 719-447-1000
  • Fax: 719-471-8841
Mailing address:
  • Phone: 719-866-6568
  • Fax: 719-538-2999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOF015692
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberDR.0061174
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: