MEDICARE: MR. KYLE J KEELEY PT

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	225100000X	Physical Therapist	1040384	TX
2	225100000X	Physical Therapist	2640	OK
3	2251S0007X	Sports Physical Therapist	1040384	TX
4	2251X0800X	Orthopedic Physical Therapist	1040384	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	80812T	OTHER	TX	BCBS PROVIDER NUMBER
3	120502	OTHER		SUPERIOR PROVIDER NUMBER
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	5385104	OTHER		AETNA PROVIDER NUMBER

General Provider Information

NPI Number	:	1922048693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KYLE J KEELEY PT

Provider Business Mailing Address
First Line	:	4005 LAMAR AVENUE
Second Line	:
City	:	PARIS
State	:	TX
Zip	:	75462-5212
Country	:	US
Telephone Number	:	903-785-3861
Fax Number	:	903-739-8768

Provider Business Practice Location Address
First Line	:	2206-B WEST MAIN
Second Line	:	HWY 82
City	:	CLARKSVILLE
State	:	TX
Zip	:	75426
Country	:	US
Telephone Number	:	903-427-1545
Fax Number	:	903-427-0078

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

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	04/04/2016

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Directions to “ MR. KYLE J KEELEY PT” Practice Location

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