Provider Demographics
NPI:1407862931
Name:SKELLY, KATHLEEN ROSE (DPM)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ROSE
Last Name:SKELLY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1692 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-4045
Mailing Address - Country:US
Mailing Address - Phone:518-869-5799
Mailing Address - Fax:518-862-1489
Practice Address - Street 1:1692 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4045
Practice Address - Country:US
Practice Address - Phone:518-869-5799
Practice Address - Fax:518-862-1489
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000942213ES0103X
NY006515213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03767782Medicaid
GA198604667AMedicaid
GA978002OtherBCBS PROVIDER NUMBER
GA48SCCRTMedicare ID - Type Unspecified
NY03767782Medicaid
GAU87020Medicare UPIN