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407 S 10th St Ste 101 Philadelphia PA 19147-1274 | |
| (267) 223-0205 | |
| (678) 487-5313 |
| Full Name | |
|---|---|
| Speciality | Family Medicine |
| Location | 407 S 10th St Ste 101, Philadelphia, Pennsylvania |
| Authorized Official Name and Position | Peter Kelly (OWNER) |
| Authorized Official Contact | 2672230205 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
407 S 10th St Ste 101 Philadelphia PA 19147-1274 Ph: (267) 223-0205 | 407 S 10th St Ste 101 Philadelphia PA 19147-1274 Ph: (267) 223-0205 |
| NPI Number | 1407514193 |
|---|---|
| Provider Enumeration Date | 11/30/2021 |
| Last Update Date | 02/11/2022 |
| Medicare PECOS PAC ID | 6406240340 |
|---|---|
| Medicare Enrollment ID | O20220218001531 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1407514193 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| Provider Name | Peter Kelly |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1982869467 PECOS PAC ID: 5092995688 Enrollment ID: I20200622001583 |
| Provider Name | Jenny Pak |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1174220636 PECOS PAC ID: 3274908694 Enrollment ID: I20230417000643 |
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