Provider Demographics
NPI:1730218736
Name:KELLY, TIMOTHY MICHAEL (DC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 COLUMBIA TURNPIKE
Mailing Address - Street 2:
Mailing Address - City:EAST GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061
Mailing Address - Country:US
Mailing Address - Phone:518-477-5000
Mailing Address - Fax:518-477-5009
Practice Address - Street 1:569 COLUMBIA TURNPIKE
Practice Address - Street 2:
Practice Address - City:EAST GREENBUSH
Practice Address - State:NY
Practice Address - Zip Code:12061
Practice Address - Country:US
Practice Address - Phone:518-477-5000
Practice Address - Fax:518-477-5009
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0075341111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY141767617OtherTAX ID