Provider Demographics
NPI:1265846810
Name:MARSZALEK, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MARSZALEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6021 MISSION TRL APT 4
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-4021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 E DOUGLAS RD STE 407
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1468
Practice Address - Country:US
Practice Address - Phone:574-335-6500
Practice Address - Fax:574-335-0772
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11017605A207Q00000X
IN01078730A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300005699Medicaid
IN000001417955OtherANTHEM
IN187720068OtherINDIANA MEDICARE
IN941050078OtherINDIANA MEDICARE
IN738460029OtherINDIANA MEDICARE
IN187720093OtherINDIANA MEDICARE
IN000001096369OtherANTHEM
IN000001223570OtherANTHEM
IN000001391392OtherANTHEM
IN000001418156OtherANTHEM
ININ1933087OtherINDIANA MEDICARE
IN300005699Medicaid