Provider Demographics
NPI:1255018834
Name:SKELLY MEDICAL GROUP LLC
Entity type:Organization
Organization Name:SKELLY MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SKELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-727-9881
Mailing Address - Street 1:7223 RIVERVIEW ST
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-6602
Mailing Address - Country:US
Mailing Address - Phone:813-727-9881
Mailing Address - Fax:
Practice Address - Street 1:2045 FOUNTAIN PROFESSIONAL CT STE C
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-5108
Practice Address - Country:US
Practice Address - Phone:850-407-1914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-05
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty