Provider Demographics
NPI:1952441982
Name:KELLEY, KEVIN V (BCO)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:V
Last Name:KELLEY
Suffix:
Gender:M
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S 17TH ST
Mailing Address - Street 2:SUITE 1902
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-5025
Mailing Address - Country:US
Mailing Address - Phone:215-567-1377
Mailing Address - Fax:215-567-5314
Practice Address - Street 1:117 S 17TH ST
Practice Address - Street 2:SUITE 1902
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-5025
Practice Address - Country:US
Practice Address - Phone:215-567-1377
Practice Address - Fax:215-567-5314
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0340570001Medicare NSC