MEDICARE: DR. TIMOTHY JOHN KELLY M.D.

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	390200000X	Student in an Organized Health Care Education/Training Program
2	208600000X	Surgery Physician	S7696	TX

General Provider Information

NPI Number	:	1558780064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY JOHN KELLY M.D.

Provider Business Mailing Address
First Line	:	2460 N IH 35 E STE 215
Second Line	:
City	:	WAXAHACHIE
State	:	TX
Zip	:	75165-5271
Country	:	US
Telephone Number	:	469-800-9830
Fax Number	:

Provider Business Practice Location Address
First Line	:	2460 N IH 35 E STE 215
Second Line	:
City	:	WAXAHACHIE
State	:	TX
Zip	:	75165-5271
Country	:	US
Telephone Number	:	469-800-9830
Fax Number	:

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

Provider Enumeration Date	:	04/11/2014
Last Update Date	:	10/12/2020

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