MEDICARE: BRYAN KELLY

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	05011222A	IN

General Provider Information

NPI Number	:	1306285564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN KELLY

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:	630-296-2223
Fax Number	:	630-759-3251

Provider Business Practice Location Address
First Line	:	3218 DAUGHERTY DR
Second Line	:	SUITE 160
City	:	LAFAYETTE
State	:	IN
Zip	:	47909-3997
Country	:	US
Telephone Number	:	765-477-6464
Fax Number	:	765-477-6262

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

Provider Enumeration Date	:	06/21/2013
Last Update Date	:	08/06/2013

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Directions to “ BRYAN KELLY ” Practice Location

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