Healthcare Provider Details

I. General information

NPI: 1073519104
Provider Name (Legal Business Name): THOMAS F KELLY JR. M.D., P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: THOMAS F KELLY JR. M.D., P.A.

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 04/05/2006

III. Provider practice location address

1540 S TAMIAMI TRL SUITE 303
SARASOTA FL
34239-2930
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-8791
  • Fax: 941-917-8793
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0034098
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberME34098
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: