Provider Demographics
NPI:1629026596
Name:KELLY, THOMAS J (DO)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 88452
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-1452
Mailing Address - Country:US
Mailing Address - Phone:205-437-6098
Mailing Address - Fax:205-437-5998
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-863-7607
Practice Address - Fax:205-437-5998
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6762207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80923OtherBCBS PROVIDER NUMBER
FL376379000Medicaid
AL059185641OtherBCBS PROVIDER NUMBER
AL059190499OtherBCBS PROVIDER NUMBER
AL059190499OtherBCBS PROVIDER NUMBER
FLA03469Medicare UPIN
FL80923TMedicare PIN
FL80923EMedicare PIN
AL059185641OtherBCBS PROVIDER NUMBER