Basic Information
| Provider Information | |||||||||
| NPI: | 1366500258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 808 N GEORGE ST | ||||||||
| Address2: | APT 3 | ||||||||
| City: | ROME | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134403410 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 107 E CHESTNUT ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | ROME | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134402834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153377952 | ||||||||
| FaxNumber: | 3153370991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 002358-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.