Provider Demographics
NPI:1992705115
Name:BETHEA, KELLY MELINDA (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MELINDA
Last Name:BETHEA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MELINDA
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 8500-8735
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-254-3289
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:PALEY 1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3018
Practice Address - Country:US
Practice Address - Phone:215-456-7170
Practice Address - Fax:215-456-4923
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2265892080A0000X
PAMD070520L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02354483Medicaid
PA102377102Medicaid
NYH18581Medicare UPIN
NY533Y31Medicare PIN
PA102377102Medicaid