Provider Demographics
NPI:1871520924
Name:KELLY, JEAN ALEXANDRA (MD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:ALEXANDRA
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:JEAN
Other - Middle Name:ALEXANDRA
Other - Last Name:HURCHALLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:564 BIERYS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-1144
Mailing Address - Country:US
Mailing Address - Phone:610-868-4475
Mailing Address - Fax:
Practice Address - Street 1:564 BIERYS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-1144
Practice Address - Country:US
Practice Address - Phone:610-868-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014781E2085R0202X
MI43010252792085R0202X
VA215692085R0202X
MDD210052085R0202X
NC223492085R0202X
IA293022085R0202X
OH35065676K2085R0202X
NY19598112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0919389Medicaid
C29056Medicare UPIN
PAKE074053Medicare ID - Type Unspecified