Provider Demographics
NPI:1144278128
Name:SMITH, KATHLEEN (DC)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:OSULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:2875 HOLME AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152
Mailing Address - Country:US
Mailing Address - Phone:215-673-1113
Mailing Address - Fax:215-673-4941
Practice Address - Street 1:2875 HOLME AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152
Practice Address - Country:US
Practice Address - Phone:215-673-1113
Practice Address - Fax:215-673-4941
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002472L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0048431000OtherINDEPENDENCE BLUE CROSS
PA0048431000OtherINDEPENDENCE BLUE CROSS
PA108975Medicare ID - Type Unspecified