=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386171684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIN MARIE KELLY DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2017
-----------------------------------------------------
Last Update Date | 11/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 S. 9TH STREET GROUND FLOOR
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-4408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-955-6585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 159 PRINCETON RD
-----------------------------------------------------
City | AUDUBON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08106-1227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081H0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | OS019802
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | OT017694
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | OT017694
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------