Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 2011-01909 | NC |
NPI | 1063449130 |
---|---|
Provider Name | Dr. Michael Thomas Kelly |
First Address | Fort Worth, TX 76112-3368 |
Second Address | Salem, VA 24153-7474 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2006 |
Last Update Date | 03/06/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5919524 | (05) | NC |
E32774 | (02) | VA |