Provider Demographics
NPI:1245418235
Name:KILEY, TIMOTHY CAMPBELL
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:CAMPBELL
Last Name:KILEY
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 1:1 CREDIT UNION WAY
Mailing Address - Street 2:FL. 3
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4633
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:377 W BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2217
Practice Address - Country:US
Practice Address - Phone:617-752-4672
Practice Address - Fax:617-752-4643
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17617225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110087951AMedicaid
MA00044601Medicare PIN