Provider Demographics
NPI:1083720908
Name:KELLNER, MARIAN (MD)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:KELLNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:345 N MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2515
Mailing Address - Country:US
Mailing Address - Phone:860-231-2476
Mailing Address - Fax:860-231-2480
Practice Address - Street 1:345 N MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2515
Practice Address - Country:US
Practice Address - Phone:860-231-2476
Practice Address - Fax:860-231-2480
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT025220207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001252204Medicaid
CT001252204Medicaid
B39606Medicare UPIN