MEDICARE: KELLY HAMILTON DELOACH MPT

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	225100000X	Physical Therapist	PT8280	GA

General Provider Information

NPI Number	:	1225051014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY HAMILTON DELOACH MPT

Provider Business Mailing Address
First Line	:	105 S 3RD AVE
Second Line	:
City	:	MC RAE
State	:	GA
Zip	:	31055-1550
Country	:	US
Telephone Number	:	229-868-2174
Fax Number	:	229-868-2175

Provider Business Practice Location Address
First Line	:	105 S 3RD AVE
Second Line	:
City	:	MC RAE
State	:	GA
Zip	:	31055-1550
Country	:	US
Telephone Number	:	229-868-2174
Fax Number	:	229-868-2175

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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