MEDICARE: ELLEN BETH KELLY 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	2255A2300X	Athletic Trainer	AT001002	GA

General Provider Information

NPI Number	:	1396776290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN BETH KELLY ATC

Provider Business Mailing Address
First Line	:	5703 NEWNAN CIR
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30106-3197
Country	:	US
Telephone Number	:	404-273-5012
Fax Number	:

Provider Business Practice Location Address
First Line	:	5040 SNAPFINGER WOODS DR
Second Line	:	SUITE 205
City	:	DECATUR
State	:	GA
Zip	:	30035-4020
Country	:	US
Telephone Number	:	678-205-5736
Fax Number	:	678-205-5739

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	07/08/2007

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