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General NPI Number Information
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NPI Number | 1871501999
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Entity Type | Individual
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Provider Name | KELLY VANDERBILT BOMER M.D.
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Gender | Female
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Dates
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Enumeration Date | 08/04/2006
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Last Update Date | 12/20/2019
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Provider Practice Location Address
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Address Line | 9155 E BELL RD
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City | SCOTTSDALE
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State | AZ
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Zip | 85260-1521
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Country | US
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Telephone | 480-889-8870
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Fax | 480-889-8871
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Provider Business Mailing Address
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Address Line | 9155 E BELL RD
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City | SCOTTSDALE
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State | AZ
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Zip | 85260-1521
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Country | US
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Telephone | 480-889-8870
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Fax | 480-889-8871
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YS0123X
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Taxonomy Name | Facial Plastic Surgery Physician
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License Number | 30302
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License Number State | AZ
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