Provider Demographics
NPI:1134681059
Name:KELLEY, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 TURNER MCCALL BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3366
Mailing Address - Country:US
Mailing Address - Phone:706-237-7223
Mailing Address - Fax:706-237-7279
Practice Address - Street 1:1903 TURNER MCCALL BLVD SE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3366
Practice Address - Country:US
Practice Address - Phone:706-237-7223
Practice Address - Fax:706-237-7279
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA054860421OtherGEORGIA IDENTIFICATION CARD