Healthcare Provider Details

I. General information

NPI: 1992705115
Provider Name (Legal Business Name): KELLY MELINDA BETHEA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY MELINDA ROBINSON M.D.

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 OLD YORK RD PALEY 1ST FLOOR
PHILADELPHIA PA
19141-3018
US

IV. Provider business mailing address

PO BOX 8500-8735
PHILADELPHIA PA
19178-0001
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-7170
  • Fax: 215-456-4923
Mailing address:
  • Phone: 215-456-7000
  • Fax: 215-254-3289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD070520L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number226589
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: