MEDICARE: MR. MATTHEW KELLY PTA

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	225200000X	Physical Therapy Assistant	40QB00269200	NJ

General Provider Information

NPI Number	:	1891025003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW KELLY PTA

Provider Business Mailing Address
First Line	:	1005 14TH AVE
Second Line	:
City	:	BELMAR
State	:	NJ
Zip	:	07719-2808
Country	:	US
Telephone Number	:	908-601-1125
Fax Number	:

Provider Business Practice Location Address
First Line	:	340 ROUTE 9
Second Line	:
City	:	BAYVILLE
State	:	NJ
Zip	:	08721-1255
Country	:	US
Telephone Number	:	732-237-7100
Fax Number	:

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

Provider Enumeration Date	:	01/11/2010
Last Update Date	:	10/18/2011

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