Basic Information
| Provider Information | |||||||||
| NPI: | 1114288685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLOSKEY | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 POPLAR AVE | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190873501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105741459 | ||||||||
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| Practice Location | |||||||||
| Address1: | 230 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157622365 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2012 | ||||||||
| LastUpdateDate: | 05/31/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MT201897 | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | MT201897 | 01 | PA | MT LICENSE | OTHER |