Provider Demographics
NPI:1831253533
Name:KELLY, PAUL COLIN (MSPT)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:COLIN
Last Name:KELLY
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 E 85TH ST APT 3B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-4580
Mailing Address - Country:US
Mailing Address - Phone:516-456-1241
Mailing Address - Fax:
Practice Address - Street 1:113 E 23RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4507
Practice Address - Country:US
Practice Address - Phone:646-742-0165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0190282251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ42802Medicare ID - Type Unspecified