Provider Demographics
NPI:1891999082
Name:HEATH, KELLY M (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:HEATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 LOMBARD STREET
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146
Mailing Address - Country:US
Mailing Address - Phone:215-662-3259
Mailing Address - Fax:
Practice Address - Street 1:1800 LOMBARD STREET
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146
Practice Address - Country:US
Practice Address - Phone:215-662-3259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07885100208100000X
PAMD450449208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE22499C92Medicare PIN