Provider Demographics
NPI:1477530632
Name:KELLY, CHRISTOPHER (PT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
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 1:2525 KANEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2578
Mailing Address - Country:US
Mailing Address - Phone:630-584-1411
Mailing Address - Fax:630-513-2630
Practice Address - Street 1:2525 KANEVILLE RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2578
Practice Address - Country:US
Practice Address - Phone:630-584-1411
Practice Address - Fax:630-513-2630
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-011747225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCF2064OtherRAILROAD GROUP
IL753210OtherMEDICARE GROUP
ILK22399Medicare PIN