Provider Demographics
NPI:1356449755
Name:KELLY, MARK CHRISTOPHER (MS, PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CHRISTOPHER
Last Name:KELLY
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 STRAWBRIDGE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-4602
Mailing Address - Country:US
Mailing Address - Phone:856-677-4000
Mailing Address - Fax:856-234-3014
Practice Address - Street 1:1 BRACE RD STE A
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034
Practice Address - Country:US
Practice Address - Phone:856-470-9191
Practice Address - Fax:856-310-9829
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00565000225100000X
NJQAO56502251X0800X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1659319002OtherADDITONAL NPI #