Provider Demographics
NPI:1942593231
Name:HOLLOWAY - MARSHALL, KELLEY ORALIVIA
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:ORALIVIA
Last Name:HOLLOWAY - MARSHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 W FULTON ST STE 303
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2345
Mailing Address - Country:US
Mailing Address - Phone:312-243-2223
Mailing Address - Fax:312-243-2227
Practice Address - Street 1:2003 W FULTON ST STE 303
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2345
Practice Address - Country:US
Practice Address - Phone:312-243-2223
Practice Address - Fax:312-243-2227
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005544213ES0103X
IN07001151A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100048065Medicaid
INP01725310OtherRAILROAD MEDICARE
IN201168580Medicaid
WIP01703698OtherRAILROAD MEDICARE
IN859800008Medicare PIN
WI100048065Medicaid