Provider Demographics
NPI:1710951678
Name:KELLY, MARTIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:901 MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2901
Mailing Address - Country:US
Mailing Address - Phone:219-836-4571
Mailing Address - Fax:219-836-4596
Practice Address - Street 1:901 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2901
Practice Address - Country:US
Practice Address - Phone:219-836-4571
Practice Address - Fax:219-836-4596
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2016-04-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL36-0852962080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD78094Medicare UPIN