Healthcare Provider Details

I. General information

NPI: 1255513313
Provider Name (Legal Business Name): BROOKE KELLY, DO, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

774 FAIRMOUNT AVE
JAMESTOWN NY
14701-2609
US

IV. Provider business mailing address

PO BOX 1258
JAMESTOWN NY
14702-1258
US

V. Phone/Fax

Practice location:
  • Phone: 716-664-7558
  • Fax: 716-664-7559
Mailing address:
  • Phone: 716-487-1124
  • Fax: 716-487-2488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number206222
License Number StateNY

VIII. Authorized Official

Name: BROOKE K KELLY
Title or Position: PRESIDENT
Credential: DO
Phone: 716-664-7558