Provider Demographics
NPI:1073519104
Name:KELLY, THOMAS F JR (MD, PA)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:F
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:MD, PA
Other - Prefix:DR
Other - First Name:THOMAS
Other - Middle Name:F
Other - Last Name:KELLY
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD, PA
Mailing Address - Street 1:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1540 S TAMIAMI TRL
Practice Address - Street 2:SUITE 303
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2930
Practice Address - Country:US
Practice Address - Phone:941-917-8791
Practice Address - Fax:941-917-8793
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2016-12-19
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
FL0034098208600000X
FLME34098208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258121300Medicaid
FL008376100Medicaid
FL68149OtherBCBS
FL258121300Medicaid
FL68149OtherBCBS