Provider Demographics
NPI:1003895798
Name:KNOWLES, KELLY P (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:P
Last Name:KNOWLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:PETRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:159 MILLBURN AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1849
Mailing Address - Country:US
Mailing Address - Phone:973-912-0155
Mailing Address - Fax:973-912-8714
Practice Address - Street 1:159 MILLBURN AVE
Practice Address - Street 2:STE 1
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1849
Practice Address - Country:US
Practice Address - Phone:973-912-0155
Practice Address - Fax:973-912-8714
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06821100208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ010068211NJ01OtherANTHEM HEALTH PIN
NJ2113135000OtherAMERIHEALTH HMO PIN
NJ1K7604OtherHEALTHNET PIN
NJ956005OtherAMERIHEALTH PPO GRP PIN
NJP2075112OtherOXFORD PIN
NJ606914OtherPHCS GRP ID
NJK4810OtherBCBS MANAGED CARE PIN
NJ0501095OtherAETNA HMO GRP ID
NJ1997280OtherUNITED HEALTH CARE PIN
NJ223285437OtherBEECH ST GRP ID
NJ7182328007OtherCIGNA PIN
NJ4102ROtherWELL CHOICE PIN
NJ001427892OtherHIGH MARK PA BLUE SHIELD
NJ223285437OtherHCPCS GRP ID
NJ2532962OtherAETNA HMO PIN