Provider Demographics
NPI:1568494722
Name:MAHAR, KELLEY (MD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:MAHAR
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 1:110 W HEWITT AVE
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-3533
Mailing Address - Country:US
Mailing Address - Phone:906-360-2636
Mailing Address - Fax:
Practice Address - Street 1:110 W HEWITT AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-3533
Practice Address - Country:US
Practice Address - Phone:906-360-2636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010737352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104430369Medicaid
MIH07899Medicare UPIN
MIN21650011Medicare PIN