Provider Demographics
NPI:1801861067
Name:KELLY, MARY (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 N OLD TURNPIKE RD
Mailing Address - Street 2:
Mailing Address - City:DRUMS
Mailing Address - State:PA
Mailing Address - Zip Code:18222-1916
Mailing Address - Country:US
Mailing Address - Phone:570-788-5357
Mailing Address - Fax:
Practice Address - Street 1:159 S OLD TURNPIKE RD
Practice Address - Street 2:
Practice Address - City:DRUMS
Practice Address - State:PA
Practice Address - Zip Code:18222-1726
Practice Address - Country:US
Practice Address - Phone:570-788-7427
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT003228L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2485028OtherAETNA HMO
PA7313174OtherAETNA PPO/POS
PAKE563880OtherPA BLUE SHIELD
PA07649810Medicaid
PA072237OtherFIRST PRIORITY HEALTH
PA07649810Medicaid