Provider Demographics
NPI:1164429114
Name:KELLEY, MARSHALL (MD)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-2219
Mailing Address - Country:US
Mailing Address - Phone:785-841-7297
Mailing Address - Fax:785-576-1587
Practice Address - Street 1:1803 W 6TH ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1710
Practice Address - Country:US
Practice Address - Phone:785-841-7297
Practice Address - Fax:785-576-1587
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0422669208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100149670AMedicaid
E41672Medicare UPIN