Provider Demographics
NPI:1134109663
Name:MARCELLINO, THOMAS R SR (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:MARCELLINO
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6265 ROCK CHALK DR
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049
Mailing Address - Country:US
Mailing Address - Phone:785-842-5070
Mailing Address - Fax:785-505-5264
Practice Address - Street 1:6265 ROCK CHALK DR
Practice Address - Street 2:SUITE 1100
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049
Practice Address - Country:US
Practice Address - Phone:785-842-5070
Practice Address - Fax:785-505-5264
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS04-32383207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200550800BMedicaid
KS110517001Medicare PIN