Healthcare Provider Details

I. General information

NPI: 1528699089
Provider Name (Legal Business Name): KELLOGG MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 11/27/2023
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10352 PARK RD
CHARLOTTE NC
28210-8401
US

IV. Provider business mailing address

10352 PARK RD
CHARLOTTE NC
28210-8401
US

V. Phone/Fax

Practice location:
  • Phone: 704-288-1097
  • Fax:
Mailing address:
  • Phone: 704-288-1097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ALAN GOODSTAT
Title or Position: COO
Credential: LCSW
Phone: 704-288-1097