Provider Demographics
NPI:1710956396
Name:HOLLOWAY, KELLY D (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2897
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-2897
Mailing Address - Country:US
Mailing Address - Phone:316-263-1574
Mailing Address - Fax:316-264-1905
Practice Address - Street 1:929 N SAINT FRANCIS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3821
Practice Address - Country:US
Practice Address - Phone:316-263-1574
Practice Address - Fax:316-264-1905
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0421912207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
050032914OtherRR MEDICARE GROUP CQ2307
KS100126900CMedicaid
KS047288OtherBCBC
KSE93218Medicare UPIN
KS100126900CMedicaid