Provider Demographics
NPI:1528222668
Name:THOMAS M. KELLY O.D., INC.
Entity Type:Organization
Organization Name:THOMAS M. KELLY O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MILO
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:440-871-1139
Mailing Address - Street 1:457 DOVER CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-2357
Mailing Address - Country:US
Mailing Address - Phone:440-871-1139
Mailing Address - Fax:440-871-0222
Practice Address - Street 1:457 DOVER CENTER RD
Practice Address - Street 2:
Practice Address - City:BAY VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44140-2357
Practice Address - Country:US
Practice Address - Phone:440-871-1139
Practice Address - Fax:440-871-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3675332B00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0528094Medicaid
OH0542481Medicare PIN