Provider Demographics
NPI:1649348194
Name:KELLEY, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 KENT AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02050-3079
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 KENT AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:MA
Practice Address - Zip Code:02050
Practice Address - Country:US
Practice Address - Phone:248-521-7181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI076453207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI425232910Medicaid
MK076453OtherCHAMPUS-CHAMPUS
290H264420OtherBLUE CROSS-BLUE CROSS
MK076453OtherCOMMERCIAL-COMMERCIAL NUMBER