Provider Demographics
NPI:1902807548
Name:KELLY, KEVIN J (MD)
Entity Type:Individual
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First Name:KEVIN
Middle Name:J
Last Name:KELLY
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1804 THORNBURY DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE GLEN
Mailing Address - State:PA
Mailing Address - Zip Code:19002-2842
Mailing Address - Country:US
Mailing Address - Phone:215-628-4530
Mailing Address - Fax:215-619-7159
Practice Address - Street 1:2701 BLAIR MILL RD
Practice Address - Street 2:SUITE 6
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1041
Practice Address - Country:US
Practice Address - Phone:215-293-8800
Practice Address - Fax:215-293-9053
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-04
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
PAMD-057754-L2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF20346Medicare UPIN