Provider Demographics
NPI:1205031671
Name:KELLEY, CECYLIA (DO)
Entity Type:Individual
Prefix:
First Name:CECYLIA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8500-6335
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:215-807-8000
Mailing Address - Fax:215-807-8235
Practice Address - Street 1:3998 RED LION RD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1436
Practice Address - Country:US
Practice Address - Phone:215-612-4963
Practice Address - Fax:215-612-4532
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013861207P00000X, 208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA30043312OtherKEYSTONE MERCY
PA38325OtherHEALTH PARTNERS
PA1019454200001Medicaid
PA2852806000OtherPERSONAL CHOICE
PA1019454200002Medicaid
PA1019454200003Medicaid
PA2852806000OtherKEYSTONE IBC
PA1973459OtherHIGHMARK BLUE SHIELD
PA1019454200003Medicaid