Basic Information
| Provider Information | |||||||||
| NPI: | 1922176361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KILEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | GERARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 396 BROADWAY | ||||||||
| Address2: | MID HUDSON PHYSICIANS, PC | ||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124014626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453313131 | ||||||||
| FaxNumber: | 8453342898 | ||||||||
| Practice Location | |||||||||
| Address1: | 396 BROADWAY | ||||||||
| Address2: | MID HUDSON PHYSICIANS, PC | ||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124014626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453313131 | ||||||||
| FaxNumber: | 8453342898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2006 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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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 | 363AM0700X | 009692 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 03834842 | 05 | NY | MEDICAID |