Provider Demographics
NPI:1871294801
Name:KELLY, THOMAS JOSEPH IV
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:KELLY
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4170 CITY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1610
Mailing Address - Country:US
Mailing Address - Phone:215-871-6100
Mailing Address - Fax:
Practice Address - Street 1:617 N 18TH ST APT 301
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-3389
Practice Address - Country:US
Practice Address - Phone:609-947-6423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program