Provider Demographics
NPI:1487750824
Name:KELLY, ERIC MICHAEL (DPT, MS, CSCS)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:DPT, MS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:WYNANTSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12198-3423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:564 HOOSICK ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2106
Practice Address - Country:US
Practice Address - Phone:518-273-2715
Practice Address - Fax:518-273-2815
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025342225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02509451Medicaid
NYRA0005Medicare ID - Type Unspecified