Provider Demographics
NPI:1811010838
Name:MCINNIS, KELLY C (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:MCINNIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 STERLING RD
Mailing Address - Street 2:APT #1
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-0712
Mailing Address - Country:US
Mailing Address - Phone:617-573-2770
Mailing Address - Fax:
Practice Address - Street 1:SPAULDING REHABILITATION HOSPITAL
Practice Address - Street 2:125 NASHUA STREET
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-573-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA231168208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation