Provider Demographics
NPI:1982869467
Name:KELLY, PETER (DO)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FEDERAL ST STE SW200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1155
Mailing Address - Country:US
Mailing Address - Phone:856-356-4924
Mailing Address - Fax:
Practice Address - Street 1:911 KINGS HWY S
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2522
Practice Address - Country:US
Practice Address - Phone:856-553-1355
Practice Address - Fax:267-376-4874
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2025-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08657700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
077356Medicare Oscar/Certification
199745SK3Medicare PIN