MEDICARE: MR. KEVIN F KELLEY SR. PA-C

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	363AM0700X	Medical Physician Assistant	0110840675	VA

General Provider Information

NPI Number	:	1881654697
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN F KELLEY SR. PA-C

Provider Business Mailing Address
First Line	:	111 STRAUSS AVE
Second Line	:
City	:	INDIAN HEAD
State	:	MD
Zip	:	20640-1524
Country	:	US
Telephone Number	:	301-744-1004
Fax Number	:	301-744-1028

Provider Business Practice Location Address
First Line	:	101 STRAUSS AVE
Second Line	:	CBIRF, 2ND MEF
City	:	INDIAN HEAD
State	:	MD
Zip	:	20640-1542
Country	:	US
Telephone Number	:	301-744-1004
Fax Number	:	301-744-1028

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

Provider Enumeration Date	:	03/24/2006
Last Update Date	:	07/08/2007

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