Provider Demographics
NPI:1235122300
Name:KELLY, EDWARD A JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:KELLY
Suffix:JR
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 1:99 MANOR AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-2620
Mailing Address - Country:US
Mailing Address - Phone:610-269-2377
Mailing Address - Fax:610-269-5022
Practice Address - Street 1:99 MANOR AVE
Practice Address - Street 2:
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335-2620
Practice Address - Country:US
Practice Address - Phone:610-269-2377
Practice Address - Fax:610-269-5022
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017677E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PWMD017677EOtherLICENSE
PA0008960230004Medicaid
PA2234277001OtherIBC ID
PA233069058OtherTAX ID
PA233069058OtherTAX ID
PA137165Medicare ID - Type Unspecified