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NPI Code Detail

MEDICARE: KELLY J. MANAHAN MD

MEDICARE: KELLY J. MANAHAN MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207VX0201XGynecologic Oncology Physician01058411AIN
2207VX0201XGynecologic Oncology Physician72318GA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1538156187
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY J. MANAHAN MD
Provider Business Mailing Address
First Line : 6920 POINTE INVERNESS WAY STE 200
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-7934
Country : US
Telephone Number : 260-479-3514
Fax Number : 260-479-3520
Provider Business Practice Location Address
First Line : 1831 5TH AVE
Second Line :
City : COLUMBUS
State : GA
Zip : 31904-8915
Country : US
Telephone Number : 706-320-8780
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/29/2005
Last Update Date : 08/31/2020

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