Healthcare Provider Details

I. General information

NPI: 1235122300
Provider Name (Legal Business Name): EDWARD A. KELLY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 03/07/2023
Certification Date: 01/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 MANOR AVE
DOWNINGTOWN PA
19335-2620
US

IV. Provider business mailing address

99 MANOR AVE
DOWNINGTOWN PA
19335-2620
US

V. Phone/Fax

Practice location:
  • Phone: 610-269-2377
  • Fax: 610-269-5022
Mailing address:
  • Phone: 610-269-2377
  • Fax: 610-269-5022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD017677E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: