Healthcare Provider Details

I. General information

NPI: 1114907458
Provider Name (Legal Business Name): PETER F KELLY D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 ELECTRIC RD
ROANOKE VA
24014-2814
US

IV. Provider business mailing address

PO BOX 20566
ROANOKE VA
24018-0057
US

V. Phone/Fax

Practice location:
  • Phone: 540-989-3338
  • Fax: 540-989-5425
Mailing address:
  • Phone: 540-989-3338
  • Fax: 540-989-5425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number0103000746
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: