=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245492818
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTON GEORGE KELLY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2008
-----------------------------------------------------
Last Update Date | 03/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 525 E 68TH ST BOX 116
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-4870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-962-8485
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 525 E 68TH STREET BOX 116
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-988-2075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | MT192522
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086S0127X
-----------------------------------------------------
Taxonomy Name | Trauma Surgery Physician
-----------------------------------------------------
License Number | 60-276050
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------