Provider Demographics
NPI:1902861313
Name:MCKELVEY, SAM (PT)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:MCKELVEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 PORT ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-1573
Mailing Address - Country:US
Mailing Address - Phone:704-654-9838
Mailing Address - Fax:
Practice Address - Street 1:5960 FAIRVIEW RD
Practice Address - Street 2:SUITE 400
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3102
Practice Address - Country:US
Practice Address - Phone:704-654-9838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5709225100000X
NC9151225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist