Healthcare Provider Details

I. General information

NPI: 1821739251
Provider Name (Legal Business Name): KELLY MARIE BRIDGHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 CHESTNUT ST FL 6
PHILADELPHIA PA
19107-4204
US

IV. Provider business mailing address

925 CHESTNUT ST FL 6
PHILADELPHIA PA
19107-4204
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-6760
  • Fax: 215-503-3736
Mailing address:
  • Phone: 215-955-6784
  • Fax: 215-923-4532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberNA
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: