Provider Demographics
NPI:1063092377
Name:KELLISH, ALEC S
Entity type:Individual
Prefix:
First Name:ALEC
Middle Name:S
Last Name:KELLISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 CHESTNUT ST FL 5
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4206
Mailing Address - Country:US
Mailing Address - Phone:267-339-3738
Mailing Address - Fax:267-339-3500
Practice Address - Street 1:925 CHESTNUT ST FL 5
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4206
Practice Address - Country:US
Practice Address - Phone:267-339-3738
Practice Address - Fax:267-339-3500
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-11
Last Update Date:2021-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program