Basic Information
| Provider Information | |||||||||
| NPI: | 1306004577 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | M.D., M.P.H. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34TH & CIVIC CENTER BOULEVARD | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF PHILADELPHIA | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 34TH & CIVIC CENTER BOULEVARD | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF PHILADELPHIA | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2008 | ||||||||
| LastUpdateDate: | 10/30/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 232262 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 442544 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.