=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942435573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY KELLEY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2009
-----------------------------------------------------
Last Update Date | 10/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1732 W HUBBARD ST STE 2A
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-6271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-675-1400
-----------------------------------------------------
Fax | 773-598-6616
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1644 N PAULINA ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-675-1400
-----------------------------------------------------
Fax | 773-598-6616
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 125053132
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------