=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528368719
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL T KELSEY JR. AAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2010
-----------------------------------------------------
Last Update Date | 03/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12902 USF MAGNOLIA DR
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33612-9416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-745-7365
-----------------------------------------------------
Fax | 813-449-8618
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 198441
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30384-8441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-745-7365
-----------------------------------------------------
Fax | 813-449-8618
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367H00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiologist Assistant
-----------------------------------------------------
License Number | AA56
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------