Provider Demographics
NPI:1497903314
Name:MARY L. KELLY, D.O., S.C.
Entity Type:Organization
Organization Name:MARY L. KELLY, D.O., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY L.
Authorized Official - Middle Name:L
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-848-0080
Mailing Address - Street 1:7319 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1220
Mailing Address - Country:US
Mailing Address - Phone:708-848-0040
Mailing Address - Fax:708-848-2931
Practice Address - Street 1:7319 NORTH AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1220
Practice Address - Country:US
Practice Address - Phone:708-848-0040
Practice Address - Fax:708-848-2931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077560261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty