Provider Demographics
NPI:1164621207
Name:MARK A KELLEY MD
Entity Type:Organization
Organization Name:MARK A KELLEY MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-747-6095
Mailing Address - Street 1:1705 E 19TH ST
Mailing Address - Street 2:512
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5405
Mailing Address - Country:US
Mailing Address - Phone:918-747-6095
Mailing Address - Fax:
Practice Address - Street 1:1705 E 19TH ST
Practice Address - Street 2:512
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5405
Practice Address - Country:US
Practice Address - Phone:918-747-6095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty