=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295116309
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTIN ELIZABETH KEAN M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2015
-----------------------------------------------------
Last Update Date | 02/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3401 N BROAD ST ZONE B - ROOM 612
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19140-5103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-707-3187
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3401 NORTH BROAD STREET ZONE B 7TH FLOOR
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-300-7787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | MT209283
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------