Healthcare Provider Details

I. General information

NPI: 1831446178
Provider Name (Legal Business Name): MARC KELLINY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2012
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 DELLWOOD ST S
CAMBRIDGE MN
55008-1920
US

IV. Provider business mailing address

701 DELLWOOD ST S
CAMBRIDGE MN
55008-1920
US

V. Phone/Fax

Practice location:
  • Phone: 763-688-8700
  • Fax:
Mailing address:
  • Phone: 763-688-8700
  • Fax: 763-688-7870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number58079
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number58079
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: