Provider Demographics
NPI:1790773547
Name:KELEPOURIS, ELLIE (MD)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:KELEPOURIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:
Other - Last Name:TZARNAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1601 CHERRY ST.
Mailing Address - Street 2:SUITE 11511
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102
Mailing Address - Country:US
Mailing Address - Phone:215-255-7822
Mailing Address - Fax:215-255-7825
Practice Address - Street 1:216 N. BROAD ST.
Practice Address - Street 2:5TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102
Practice Address - Country:US
Practice Address - Phone:215-762-1147
Practice Address - Fax:215-762-1904
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038124L207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008593700002Medicaid
PA058493EASMedicare ID - Type Unspecified
B34563Medicare UPIN