Provider Demographics
NPI:1932632049
Name:KETCHEM, CLAIRE ELIZABETH
Entity Type:Individual
Prefix:
First Name:CLAIRE
Middle Name:ELIZABETH
Last Name:KETCHEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4824
Mailing Address - Country:US
Mailing Address - Phone:984-974-4462
Mailing Address - Fax:
Practice Address - Street 1:111 S 11TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4824
Practice Address - Country:US
Practice Address - Phone:215-955-7785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD477849207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program