MEDICARE: DR. KELLY DEAN SKANCHY M.D.

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	207QS0010X	Sports Medicine (Family Medicine) Physician	MD044935L	PA
2	207QS0010X	Sports Medicine (Family Medicine) Physician	GFE83510	CA

General Provider Information

NPI Number	:	1154313971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY DEAN SKANCHY M.D.

Provider Business Mailing Address
First Line	:	2450 CRAVEN ST BLDG 3300
Second Line	:	NAVAL HEALTH CLINIC NAVAL BASE SAN DIEGO
City	:	SAN DIEGO
State	:	CA
Zip	:	92136-5599
Country	:	US
Telephone Number	:	619-556-5936
Fax Number	:	619-556-9419

Provider Business Practice Location Address
First Line	:	2450 CRAVEN ST BLDG 3300
Second Line	:	NAVAL HEALTH CLINIC NAVAL STATION SAN DIEGO
City	:	SAN DIEGO
State	:	CA
Zip	:	92136-5599
Country	:	US
Telephone Number	:	619-556-5936
Fax Number	:	619-556-9419

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	04/29/2014

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