Provider Demographics
NPI:1083409361
Name:RICCIO, KELLY (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RICCIO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 EMERALD RD
Mailing Address - Street 2:
Mailing Address - City:GILBERTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19525-8406
Mailing Address - Country:US
Mailing Address - Phone:215-237-0183
Mailing Address - Fax:
Practice Address - Street 1:2830 EASTON AVE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-4204
Practice Address - Country:US
Practice Address - Phone:484-526-3555
Practice Address - Fax:833-822-5230
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT233345207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine