Provider Demographics
NPI:1114288685
Name:MCCLOSKEY, KRISTIN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:MCCLOSKEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-3501
Mailing Address - Country:US
Mailing Address - Phone:610-574-1459
Mailing Address - Fax:
Practice Address - Street 1:230 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1121
Practice Address - Country:US
Practice Address - Phone:215-762-2365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT201897207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMT201897OtherMT LICENSE