Provider Demographics
NPI:1962475582
Name:MARSHALL, KELLEY W (MD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:W
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:7795 LANDOWNE DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-1063
Mailing Address - Country:US
Mailing Address - Phone:770-730-8535
Mailing Address - Fax:770-730-8535
Practice Address - Street 1:7795 LANDOWNE DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-1063
Practice Address - Country:US
Practice Address - Phone:770-730-8535
Practice Address - Fax:770-730-8535
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0483722085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000852893Medicaid
IN200928350Medicaid
KY50019563OtherPASSPORT/NORTON
KY000023033OOtherHUMANA/NORTON
KY00533044OtherMEDICARE
KY7100044200OtherKY MEDICAID-NORTON
KY096946OtherSIHO/NORTON
KY000000568993OtherANTHEM/NORTON