Provider Demographics
NPI:1225138340
Name:MEDLEY, MARSHALL KEVIN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:KEVIN
Last Name:MEDLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35600 CENTRAL CITY PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2046
Practice Address - Country:US
Practice Address - Phone:734-421-1000
Practice Address - Fax:734-421-1001
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010137692086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI141412OtherCARE CHOICES
MI4774341Medicaid
MI0007367710OtherAETNA
MI5821256OtherBLUE CROSS BLUE SHIELD
MIU92085OtherPRIVATE HEALTH CARE SYSTE
MI000000012192OtherCAPE HEALTH PLAN
MI17178OtherMCARE
MIP36227-FOtherBLUE CARE NETWORK
MIU92085OtherPRIVATE HEALTH CARE SYSTE
0P18720Medicare PIN