MEDICARE: ROBERTA M KILLEEN MD PA

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	291U00000X	Clinical Medical Laboratory	800009658	FL

General Provider Information

NPI Number	:	1609039361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROBERTA M KILLEEN MD PA

Provider Business Mailing Address
First Line	:	2520 US HIGHWAY 19
Second Line	:
City	:	HOLIDAY
State	:	FL
Zip	:	34691-3846
Country	:	US
Telephone Number	:	727-939-1584
Fax Number	:

Provider Business Practice Location Address
First Line	:	2520 US HIGHWAY 19
Second Line	:
City	:	HOLIDAY
State	:	FL
Zip	:	34691-3846
Country	:	US
Telephone Number	:	727-939-1584
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERTA M KILLEEN
Credential	:	MD
Telephone Number	:	727-939-1584

Provider Enumeration Date	:	07/02/2008
Last Update Date	:	07/02/2008

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