Provider Demographics
NPI:1013905512
Name:KELLY, WILLIAM KEVIN (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KEVIN
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 CHESTNUT ST
Mailing Address - Street 2:SUITE 320A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4216
Mailing Address - Country:US
Mailing Address - Phone:215-995-8874
Mailing Address - Fax:215-955-2340
Practice Address - Street 1:925 CHESTNUT ST
Practice Address - Street 2:SUITE 320A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4216
Practice Address - Country:US
Practice Address - Phone:215-995-8874
Practice Address - Fax:215-955-2340
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043422207RX0202X
PAOS006196L207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102474035Medicaid
CT001434224Medicaid
NJ0232017Medicaid
NJ0232017Medicaid
PA185669Medicare PIN
PA102474035Medicaid