Healthcare Provider Details

I. General information

NPI: 1922032333
Provider Name (Legal Business Name): BREWSTER A KELLOGG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 SW ABBEY ST
NEWPORT OR
97365-4820
US

IV. Provider business mailing address

310 E COLLEGE DR
COLBY KS
67701-3716
US

V. Phone/Fax

Practice location:
  • Phone: 541-265-2244
  • Fax:
Mailing address:
  • Phone: 785-462-6184
  • Fax: 785-460-1490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0530778
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO198303
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: