Provider Demographics
NPI:1679959787
Name:PATRICIA KELLY MEDICAL PC
Entity Type:Organization
Organization Name:PATRICIA KELLY MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLANCY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-646-2228
Mailing Address - Street 1:225 WIRELESS BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-3914
Mailing Address - Country:US
Mailing Address - Phone:877-646-2228
Mailing Address - Fax:877-922-3329
Practice Address - Street 1:2171 JERICHO TPKE
Practice Address - Street 2:SUITE 100
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2937
Practice Address - Country:US
Practice Address - Phone:877-646-2228
Practice Address - Fax:877-922-3329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232224-1207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty