Healthcare Provider Details

I. General information

NPI: 1790773547
Provider Name (Legal Business Name): ELLIE KELEPOURIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLIE TZARNAS MD

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 N. BROAD ST. 5TH FLOOR
PHILADELPHIA PA
19102
US

IV. Provider business mailing address

1601 CHERRY ST. SUITE 11511
PHILADELPHIA PA
19102
US

V. Phone/Fax

Practice location:
  • Phone: 215-762-1147
  • Fax: 215-762-1904
Mailing address:
  • Phone: 215-255-7822
  • Fax: 215-255-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD038124L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: