Provider Demographics
NPI:1093702441
Name:KELLY, TIMOTHY P (PT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:KELLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 CLAREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:TAMAQUA
Mailing Address - State:PA
Mailing Address - Zip Code:18252-4431
Mailing Address - Country:US
Mailing Address - Phone:570-668-1889
Mailing Address - Fax:570-668-6115
Practice Address - Street 1:219 CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:TAMAQUA
Practice Address - State:PA
Practice Address - Zip Code:18252-4431
Practice Address - Country:US
Practice Address - Phone:570-668-1889
Practice Address - Fax:570-668-6115
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT000431225100000X
2251E1200X, 2251G0304X, 2251X0800X, 2251P0200X, 2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
03022001OtherCAPITAL BLUE CROSS
102808OtherHIGHMARK BLUE SHIELD
43037000OtherINDEPENDENCE BLUE CROSS
102808OtherKEYSTONE
11228087OtherCAQH
072236OtherFIRST PRIORITY HEALTH
2106682OtherAETNA HMO
0202760OtherHEALTH ASSURANCE
5039607OtherAETNA PPO
R06074Medicare UPIN
0202760OtherHEALTH ASSURANCE