Provider Demographics
NPI:1083670830
Name:KELLEY, MANUEL R (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:R
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1285
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-1285
Mailing Address - Country:US
Mailing Address - Phone:870-543-2380
Mailing Address - Fax:870-535-4716
Practice Address - Street 1:1101 TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601-5801
Practice Address - Country:US
Practice Address - Phone:870-543-2380
Practice Address - Fax:870-535-4716
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-5328207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1159400000OtherQUAL CHOICE
AR52821OtherMEDICARE
AR0120403OtherUNITED HEALTH CARE
AR103173001Medicaid
ARC68619OtherUPIN