Healthcare Provider Details

I. General information

NPI: 1083409361
Provider Name (Legal Business Name): KELLY RICCIO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2830 EASTON AVE
BETHLEHEM PA
18017-4204
US

IV. Provider business mailing address

710 EMERALD RD
GILBERTSVILLE PA
19525-8406
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-3555
  • Fax: 833-822-5230
Mailing address:
  • Phone: 215-237-0183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMT233345
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: