Provider Demographics
NPI:1548608920
Name:BAZELAIS, JAMES KELLY (OTA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:KELLY
Last Name:BAZELAIS
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:944 E JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19138-1065
Mailing Address - Country:US
Mailing Address - Phone:267-983-7030
Mailing Address - Fax:
Practice Address - Street 1:600 S BROAD ST
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-3346
Practice Address - Country:US
Practice Address - Phone:610-924-4561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP007379247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other