Basic Information
| Provider Information | |||||||||
| NPI: | 1629026596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 88452 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606801452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054376098 | ||||||||
| FaxNumber: | 2054375998 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 MAR WALT DR | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508637607 | ||||||||
| FaxNumber: | 2054375998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 03/20/2009 | ||||||||
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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 | 207P00000X | OS6762 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 80923 | 01 | FL | BCBS PROVIDER NUMBER | OTHER | 376379000 | 05 | FL | MEDICAID | 059185641 | 01 | AL | BCBS PROVIDER NUMBER | OTHER | 059190499 | 01 | AL | BCBS PROVIDER NUMBER | OTHER |