Provider Demographics
NPI:1356343743
Name:FIFE, KELLY D (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:D
Last Name:FIFE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1295 ROUTE 38
Mailing Address - Street 2:P.O.BOX 479
Mailing Address - City:HAINESPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:08036-2702
Mailing Address - Country:US
Mailing Address - Phone:609-261-7017
Mailing Address - Fax:609-261-4180
Practice Address - Street 1:175 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NJ
Practice Address - Zip Code:08060-2038
Practice Address - Country:US
Practice Address - Phone:609-267-0700
Practice Address - Fax:609-261-4180
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA040839002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3715400Medicaid
NJ043320Medicare ID - Type Unspecified
NJ3715400Medicaid