Basic Information
| Provider Information | |||||||||
| NPI: | 1285635748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELEPOURIS | ||||||||
| FirstName: | NICKY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | TANOS | ||||||||
| OtherFirstName: | NICKY | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2300 COMPUTER RD | ||||||||
| Address2: | SUITE H-39 | ||||||||
| City: | WILLOW GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190901752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156755200 | ||||||||
| FaxNumber: | 2156578083 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 COMPUTER RD | ||||||||
| Address2: | SUITE H-39 | ||||||||
| City: | WILLOW GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190901752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156755200 | ||||||||
| FaxNumber: | 2156578083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | MD0039830L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.