Healthcare Provider Details

I. General information

NPI: 1619339850
Provider Name (Legal Business Name): KELLIE CHIU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2016
Last Update Date: 02/17/2024
Certification Date: 02/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 SECOND STREET PIKE
SOUTHAMPTON PA
18966-3822
US

IV. Provider business mailing address

PO BOX 787512
PHILADELPHIA PA
19178-7512
US

V. Phone/Fax

Practice location:
  • Phone: 800-818-4747
  • Fax: 410-354-0186
Mailing address:
  • Phone:
  • Fax: 410-354-0186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number309561
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA11474600
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME161054
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC1-0025071
License Number StateDE
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD477605
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: