Healthcare Provider Details

I. General information

NPI: 1558523258
Provider Name (Legal Business Name): KELLY T BADGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY T KRUEGER MD

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 JACKSON ST
OSHKOSH WI
54901-1513
US

IV. Provider business mailing address

2725 JACKSON ST
OSHKOSH WI
54901-1513
US

V. Phone/Fax

Practice location:
  • Phone: 920-223-7500
  • Fax:
Mailing address:
  • Phone: 920-223-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number555699
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: