Provider Demographics
NPI:1023063682
Name:MCGUIRE, KELLY WAYNE (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:WAYNE
Last Name:MCGUIRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6301 UNIVERSITY COMMONS
Mailing Address - Street 2:STE 230
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1571
Mailing Address - Country:US
Mailing Address - Phone:574-251-2100
Mailing Address - Fax:574-251-2151
Practice Address - Street 1:6301 UNIVERSITY COMMONS
Practice Address - Street 2:SUITE 310
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1571
Practice Address - Country:US
Practice Address - Phone:574-232-1471
Practice Address - Fax:574-239-8511
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2011-09-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01060309207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000621003OtherBCBS
IN200523290Medicaid
IN735850XMedicare PIN
INI35100Medicare UPIN