Provider Demographics
NPI:1871593004
Name:KELLY, ANDREW EDWARD (PT)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:EDWARD
Last Name:KELLY
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 1:165 N REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1970
Mailing Address - Country:US
Mailing Address - Phone:415-499-0278
Mailing Address - Fax:415-499-0297
Practice Address - Street 1:165 N REDWOOD DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1969
Practice Address - Country:US
Practice Address - Phone:415-499-0278
Practice Address - Fax:415-499-0297
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15707225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT15707OtherBLUE SHIELD IND PROV NO
CAZZZ64636ZOtherBLUE SHIELD GROUP NUMBER
CAOPT15707OtherBLUE SHIELD IND PROV NO