MEDICARE: KELLY MELINDA BETHEA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	226589	NY
2	208000000X	Pediatrics Physician	MD070520L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992705115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MELINDA BETHEA MD

Provider Business Mailing Address
First Line	:	PO BOX 8500-8735
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19178-0001
Country	:	US
Telephone Number	:	215-456-7000
Fax Number	:	215-254-3289

Provider Business Practice Location Address
First Line	:	5501 OLD YORK RD
Second Line	:	PALEY 1ST FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19141-3018
Country	:	US
Telephone Number	:	215-456-7170
Fax Number	:	215-456-4923

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	08/28/2014

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