Healthcare Provider Details

I. General information

NPI: 1164429114
Provider Name (Legal Business Name): MARSHALL KELLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1803 W 6TH ST
LAWRENCE KS
66044-1710
US

IV. Provider business mailing address

1312 W 6TH ST
LAWRENCE KS
66044-2219
US

V. Phone/Fax

Practice location:
  • Phone: 785-841-7297
  • Fax: 785-856-0375
Mailing address:
  • Phone: 785-841-7297
  • Fax: 785-856-0375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0422669
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100149670A
Identifier TypeMEDICAID
Identifier StateKS
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: