NPIMap

Individual provider Active NPI

Kelly Alice Drivdahl Dougherty, MD

  • Emergency Medicine Physician
  • Philadelphia, PA
National Provider Identifier
1336709096
Registry record updated May 1, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emergency Medicine PhysicianTaxonomy code 207P00000X
License
MT218870 Issued in PA
Practice address
3401 N Broad St
Philadelphia, PA 19140-5189
Phone
(215) 707-5435
NPI assigned
Jun 15, 2019
Last updated
May 1, 2023By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 1, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medicine Physician 207P00000X MT218870 PA Primary

Addresses

Primary practice location

3401 N Broad St
Philadelphia, PA 19140-5189

Mailing address

1620 Mount Vernon St Apt 3
Philadelphia, PA 19130-3320
Phone (484) 350-2351

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address kdougherty150523@nyumc.direct-ci.com

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20220809001308 NY Practitioner - Emergency Medicine 9436485935 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Emergency Medicine
Education
New York University School of Medicine, 2019
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
New York UniversityGroup PAC ID 1355232422, 5,925 clinicians

Practice addresses (Care Compare)

111 Broadway
New York, NY 10006-1901
Phone (212) 263-9700

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
90.8 of 100Reported as group
Quality
91.79
Promoting interoperability
100
Improvement activities
40
Cost
75.18

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
MT218870PAMDEmergency Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
New York University CurrentSince Jul 1, 2022 Accepting new patients
New York University Emergency Medicine CurrentSince Jul 1, 2022 Accepting new patients

Locations

14 Wall St
Fl 9
Wall Street, NY 10005
Phone (646) 501-3224

Networks

  • Healthfirst Medicare Network H9678

Interoperability endpoints

  • Direct secure messaging: kdougherty150523@nyumc.direct-ci.com
  • Direct secure messaging: kdougherty674925@nychhc.direct-ci.com

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1560556800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1682899200000",
    "number": "1336709096",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1620 MOUNT VERNON ST APT 3",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191303320",
            "telephone_number": "484-350-2351"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3401 N BROAD ST",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191405189",
            "telephone_number": "215-707-5435"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DOUGHERTY",
        "first_name": "KELLY",
        "middle_name": "ALICE DRIVDAHL",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-06-15",
        "last_updated": "2023-05-01",
        "certification_date": "2023-05-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "PA",
            "license": "MT218870",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "kdougherty150523@nyumc.direct-ci.com",
            "affiliation": "N",
            "address_1": "570 1st Ave",
            "city": "New York",
            "state": "NY",
            "country_code": "US",
            "postal_code": "100166512",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Philadelphia, PA

Sources for this page

Verify at the official NPI Registry.