Provider Demographics
NPI:1619339850
Name:CHIU, KELLIE
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:CHIU
Suffix:
Gender:F
Credentials:
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 787512
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-7512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:410-354-0186
Practice Address - Street 1:45 SECOND STREET PIKE
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3822
Practice Address - Country:US
Practice Address - Phone:800-818-4747
Practice Address - Fax:410-354-0186
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-27
Last Update Date:2024-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3095612085R0202X
NJ25MA114746002085R0202X
FLME1610542085R0202X
DEC1-00250712085R0202X
390200000X
PAMD4776052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program