MEDICARE: ROBERT W. KELLEY ODPC

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	152W00000X	Optometrist	349	MT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	0642010001	OTHER	MT	DME MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	26620	OTHER	MT	BLUE CROSS/BLUE SHIELD MT
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578655528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROBERT W. KELLEY ODPC

Provider Business Mailing Address
First Line	:	PO BOX 399
Second Line	:
City	:	THOMPSON FALLS
State	:	MT
Zip	:	59873-0399
Country	:	US
Telephone Number	:	406-827-4327
Fax Number	:	406-827-3027

Provider Business Practice Location Address
First Line	:	401 MAIN STREET
Second Line	:
City	:	THOMPSON FALLS
State	:	MT
Zip	:	59873-0399
Country	:	US
Telephone Number	:	406-827-4327
Fax Number	:	406-827-3027

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT W KELLEY
Credential	:
Telephone Number	:	406-827-4327

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	02/01/2008

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