MEDICARE: KELLY MASON DAVIS

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	208100000X	Physical Medicine & Rehabilitation Physician	22229	FL

General Provider Information

NPI Number	:	1841775087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MASON DAVIS

Provider Business Mailing Address
First Line	:	1601 VERMONT AVE
Second Line	:
City	:	LYNN HAVEN
State	:	FL
Zip	:	32444-3566
Country	:	US
Telephone Number	:	850-814-5456
Fax Number	:

Provider Business Practice Location Address
First Line	:	1336 SAINT ANDREWS BLVD
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-2762
Country	:	US
Telephone Number	:	850-763-3911
Fax Number	:

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

Provider Enumeration Date	:	10/02/2018
Last Update Date	:	10/02/2018

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