Healthcare Provider Details

I. General information

NPI: 1063449130
Provider Name (Legal Business Name): MICHAEL THOMAS KELLY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 ELECTRIC RD
SALEM VA
24153-7474
US

IV. Provider business mailing address

6707 BRENTWOOD STAIR RD STE 600
FORT WORTH TX
76112-3368
US

V. Phone/Fax

Practice location:
  • Phone: 817-284-9850
  • Fax: 817-720-9892
Mailing address:
  • Phone: 817-284-9850
  • Fax: 817-720-9892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number2011-01909
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2011-01909
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: