MEDICARE: DR. MARK DAMIEN KELLEY MD

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	207R00000X	Internal Medicine Physician	9072	RI

General Provider Information

NPI Number	:	1952351447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK DAMIEN KELLEY MD

Provider Business Mailing Address
First Line	:	1130 TEN ROD RD
Second Line	:	STE D103
City	:	NORTH KINGSTOWN
State	:	RI
Zip	:	02852-4179
Country	:	US
Telephone Number	:	401-295-4409
Fax Number	:	401-295-1209

Provider Business Practice Location Address
First Line	:	1130 TEN ROD RD
Second Line	:	THE MEADOWS BUILDING D, STE 103
City	:	NORTH KINGSTOWN
State	:	RI
Zip	:	02852-4179
Country	:	US
Telephone Number	:	401-295-4409
Fax Number	:	401-295-1209

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

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	03/05/2008

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