1245451962 NPI number — MARIE A KELLY PT

Table of content: MARIE A KELLY PT (NPI 1245451962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245451962 NPI number — MARIE A KELLY PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
MARIE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245451962
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
335 OAK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW WINDSOR
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12553-5808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-496-7240
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 N ROUTE 9W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST HAVERSTRAW
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10993-1127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-786-4162
Provider Business Practice Location Address Fax Number:
845-786-4031
Provider Enumeration Date:
05/01/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  5921-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)