=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720112477
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HABIB R. KELLY M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6112 TORRESDALE AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19135-3718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-333-7437
-----------------------------------------------------
Fax | 215-333-9558
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6112 TORRESDALE AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19135-3718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-333-7437
-----------------------------------------------------
Fax | 215-333-9558
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HABIB R KELLY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 215-333-7437
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MD031034L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------