Provider Demographics
NPI:1366500258
Name:KELLY, MICHAEL R
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 N GEORGE ST
Mailing Address - Street 2:APT 3
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-3410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 E CHESTNUT ST
Practice Address - Street 2:SUITE 104
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2834
Practice Address - Country:US
Practice Address - Phone:315-337-7952
Practice Address - Fax:315-337-0991
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002358-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant