MEDICARE: LESA A KELLY MD

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	174400000X	Specialist	191220	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	A400003316	OTHER	NY	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1358881	OTHER	NY	MAGNACARE PROVIDER ID
2	P1844761	OTHER	NY	OXFORD ID
4	010191220NY01	OTHER	NY	EMPIRE GOV PAN PROVIDER I
5	134081364	OTHER	NY	TAX ID
6	2200529	OTHER	NY	GHI
7	2295900	OTHER	NY	AETNA PROVIDER ID

General Provider Information

NPI Number	:	1265598015
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESA A KELLY MD

Provider Business Mailing Address
First Line	:	34 TRENOR DR
Second Line	:
City	:	NEW ROCHELLE
State	:	NY
Zip	:	10804-3719
Country	:	US
Telephone Number	:	914-637-2663
Fax Number	:	914-632-2016

Provider Business Practice Location Address
First Line	:	1296 NORTH AVE
Second Line	:	SUITE 201
City	:	NEW ROCHELLE
State	:	NY
Zip	:	10804-2603
Country	:	US
Telephone Number	:	914-637-2663
Fax Number	:	914-632-2016

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

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	01/28/2015

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Directions to “ LESA A KELLY MD” Practice Location

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