MEDICARE: KELLY BRAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	036.127747	IL
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1043525785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY BRAY

Provider Business Mailing Address
First Line	:	2035 S INDIANA AVE
Second Line	:	312
City	:	CHICAGO
State	:	IL
Zip	:	60616-4925
Country	:	US
Telephone Number	:	773-209-9925
Fax Number	:

Provider Business Practice Location Address
First Line	:	2035 S INDIANA AVE
Second Line	:	312
City	:	CHICAGO
State	:	IL
Zip	:	60616-4925
Country	:	US
Telephone Number	:	773-209-9925
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2010
Last Update Date	:	12/09/2011

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