Provider Demographics
NPI:1811027998
Name:EBERHARDT, KELLY JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JEAN
Last Name:EBERHARDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:55 WATER ST
Mailing Address - Street 2:2ND FLOOR CRED DEPT
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:1050 CLOVE ROAD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3627
Practice Address - Country:US
Practice Address - Phone:718-270-1480
Practice Address - Fax:718-816-3739
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY234824208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02887378Medicaid
NYA400160710Medicare PIN