Healthcare Provider Details

I. General information

NPI: 1700462132
Provider Name (Legal Business Name): KELLAN PATRICK ETTER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ADELBERT RD
CLEVELAND OH
44106-2624
US

IV. Provider business mailing address

2101 ADELBERT RD
CLEVELAND OH
44106-2624
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-3911
  • Fax:
Mailing address:
  • Phone: 216-844-3911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number34.017038
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: