Provider Demographics
NPI:1043701477
Name:KELLY, MARCUS D
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:D
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 ASBURY DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-1806
Mailing Address - Country:US
Mailing Address - Phone:419-508-1199
Mailing Address - Fax:
Practice Address - Street 1:500 MADISON AVE STE 300
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-1257
Practice Address - Country:US
Practice Address - Phone:567-312-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator