Healthcare Provider Details

I. General information

NPI: 1366500258
Provider Name (Legal Business Name): MICHAEL R KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E CHESTNUT ST SUITE 104
ROME NY
13440-2834
US

IV. Provider business mailing address

808 N GEORGE ST APT 3
ROME NY
13440-3410
US

V. Phone/Fax

Practice location:
  • Phone: 315-337-7952
  • Fax: 315-337-0991
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number002358-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: