MEDICARE: MR. DENNIS WILLIAM KELLINGTON MA, ATC

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	225500000X	Respiratory/Developmental/Rehabilitative Specialist/Technologist	001364-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001364-1	OTHER	NY	ATHLETIC TRAINER LICENSE

General Provider Information

NPI Number	:	1205869500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DENNIS WILLIAM KELLINGTON MA, ATC

Provider Business Mailing Address
First Line	:	MANLEY FIELD HOUSE
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13244-5020
Country	:	US
Telephone Number	:	315-443-4775
Fax Number	:	315-443-5057

Provider Business Practice Location Address
First Line	:	MANLEY FIELD HOUSE
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13244-5020
Country	:	US
Telephone Number	:	315-443-4775
Fax Number	:	315-443-5057

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

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	07/08/2007

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