Provider Demographics
NPI:1497848485
Name:KELLY, MATTHEW S (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
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 1:28610 425 E ST
Mailing Address - Street 2:
Mailing Address - City:TAMPICO
Mailing Address - State:IL
Mailing Address - Zip Code:61283-9137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23915 W MAIN ST
Practice Address - Street 2:SUITES A&B
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-1967
Practice Address - Country:US
Practice Address - Phone:815-609-0570
Practice Address - Fax:815-609-1026
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK39790Medicare PIN