Provider Demographics
NPI:1093270522
Name:KELSO NEUROMONITORING PLLC
Entity Type:Organization
Organization Name:KELSO NEUROMONITORING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:K
Authorized Official - Last Name:PUTTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-310-7334
Mailing Address - Street 1:DEPT # 880459 PO BOX 29650
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9650
Mailing Address - Country:US
Mailing Address - Phone:800-310-7334
Mailing Address - Fax:
Practice Address - Street 1:10981 N CAMINO DE OESTE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85742-9121
Practice Address - Country:US
Practice Address - Phone:800-310-7334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-08
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ20640OtherMEDICAL LICENSE