Provider Demographics
NPI:1962479642
Name:SKELLEY, MARK J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:SKELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3126 S JACKSON AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-2534
Mailing Address - Country:US
Mailing Address - Phone:417-556-3400
Mailing Address - Fax:417-556-3401
Practice Address - Street 1:3126 S JACKSON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-2534
Practice Address - Country:US
Practice Address - Phone:417-556-3400
Practice Address - Fax:417-556-3401
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2016-10-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOMDR7C50207RH0003X
MOR7C50207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100135900AMedicaid
MO25164OtherBLUE CROSS
OK100175490AMedicaid
MO201844727Medicaid
MO201844743Medicaid
OK100175490AMedicaid
MO201844743Medicaid
KSJ108395Medicare ID - Type Unspecified
MO001011738Medicare ID - Type Unspecified
OK100175490AMedicaid
MO201844743Medicaid