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NPI Code Detail

MEDICARE: LAURA KELLEY D.O.

MEDICARE: LAURA KELLEY D.O.
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
1208000000XPediatrics Physician1865ME

General Provider Information

NPI Number : 1558348763
Entity Type Code : Individual
Provider Name (Legal Business Name) : LAURA KELLEY D.O.
Provider Business Mailing Address
First Line : 295 FOREST AVE
Second Line : 2ND FLOOR
City : PORTLAND
State : ME
Zip : 04101-2018
Country : US
Telephone Number : 207-772-5437
Fax Number : 207-879-1537
Provider Business Practice Location Address
First Line : 295 FOREST AVE
Second Line : 2ND FLOOR
City : PORTLAND
State : ME
Zip : 04101-2018
Country : US
Telephone Number : 207-772-5437
Fax Number : 207-879-1537
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/29/2005
Last Update Date : 07/08/2007

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