Basic Information
| Provider Information | |||||||||
| NPI: | 1336709096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ALICE DRIVDAHL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1620 MOUNT VERNON ST APT 3 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191303320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843502351 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3401 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157075435 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2019 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MT218870 | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.