MEDICARE: DR. KELLY GAYLE THORSTAD 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	208000000X	Pediatrics Physician	L0651	TX

General Provider Information

NPI Number	:	1174508832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY GAYLE THORSTAD M.D.

Provider Business Mailing Address
First Line	:	12174 N MO PAC EXPY
Second Line	:	SUITE A
City	:	AUSTIN
State	:	TX
Zip	:	78758-2910
Country	:	US
Telephone Number	:	512-833-7334
Fax Number	:	512-833-7333

Provider Business Practice Location Address
First Line	:	12174 N MO PAC EXPY
Second Line	:	SUITE A
City	:	AUSTIN
State	:	TX
Zip	:	78758-2910
Country	:	US
Telephone Number	:	512-833-7334
Fax Number	:	512-833-7333

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

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	07/23/2007

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