MEDICARE: EPHRAIM KELLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386134534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EPHRAIM KELLY

Provider Business Mailing Address
First Line	:	1235 SPRING GARDEN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19123-3206
Country	:	US
Telephone Number	:	215-769-3561
Fax Number	:	215-769-3860

Provider Business Practice Location Address
First Line	:	1235 SPRING GARDEN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19123-3206
Country	:	US
Telephone Number	:	215-769-3561
Fax Number	:	215-769-3860

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2018
Last Update Date	:	05/14/2018

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Directions to “ EPHRAIM KELLY ” Practice Location

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