Healthcare Provider Details

I. General information

NPI: 1164683157
Provider Name (Legal Business Name): DR MARY KELLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7319 NORTH AVE
RIVER FOREST IL
60305-1220
US

IV. Provider business mailing address

7319 NORTH AVE
RIVER FOREST IL
60305-1220
US

V. Phone/Fax

Practice location:
  • Phone: 708-848-0040
  • Fax:
Mailing address:
  • Phone: 708-848-0040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036077560
License Number StateIL

VIII. Authorized Official

Name: MARY KELLY
Title or Position: OWNER
Credential:
Phone: 708-848-0040