MEDICARE: EMILY 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	225100000X	Physical Therapist	PT019366	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3528774000	OTHER	PA	PERSONAL CHOICE/KEYSTONE (IBC)

General Provider Information

NPI Number	:	1417124645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY KELLY

Provider Business Mailing Address
First Line	:	475 ALLENDALE RD STE 206
Second Line	:
City	:	KING OF PRUSSIA
State	:	PA
Zip	:	19406-1495
Country	:	US
Telephone Number	:	610-270-0370
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 E LANCASTER AVE STE 205
Second Line	:
City	:	ARDMORE
State	:	PA
Zip	:	19003-3209
Country	:	US
Telephone Number	:	484-297-6491
Fax Number	:

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

Provider Enumeration Date	:	05/16/2008
Last Update Date	:	02/09/2021

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