Provider Demographics
NPI:1811968621
Name:KELLEY, KRISTINE (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
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:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:225 PENN AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-1921
Practice Address - Country:US
Practice Address - Phone:570-342-7864
Practice Address - Fax:570-342-7119
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-032146-E173000000X
PAMD032146E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011243520001Medicaid
PA0011243520001Medicaid
PAE07143Medicare UPIN