Healthcare Provider Details

I. General information

NPI: 1457918450
Provider Name (Legal Business Name): ROBERT FRANCIS KELLY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 EMERSON RD STE 20
CREVE COEUR MO
63141-6739
US

IV. Provider business mailing address

633 EMERSON RD STE 20
CREVE COEUR MO
63141-6739
US

V. Phone/Fax

Practice location:
  • Phone: 314-325-3068
  • Fax:
Mailing address:
  • Phone: 314-325-3068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2020042060
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00522100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: