Healthcare Provider Details

I. General information

NPI: 1861055816
Provider Name (Legal Business Name): DELALI KEVIN KWAMIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

9953 E HILL DR
LORTON VA
22079-2431
US

V. Phone/Fax

Practice location:
  • Phone: 800-836-7536
  • Fax:
Mailing address:
  • Phone: 571-344-0013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number104062
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number251181
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT222608
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: