Provider Demographics
NPI:1538158472
Name:KELLY, JOHN D IV (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:KELLY
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:2 SILVERSTEIN BUILDING
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-3340
Mailing Address - Fax:215-349-5928
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:2 SILVERSTEIN BUILDING
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-3340
Practice Address - Fax:215-349-5928
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034751E207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012052630001Medicaid
PA610070Medicare PIN
E71369Medicare UPIN