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General NPI Number Information
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NPI Number | 1255601944
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Entity Type | Organization
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Legal Business Name | FORT SCOTT FAMILY MEDICINE
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Dates
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Enumeration Date | 01/11/2012
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Last Update Date | 08/01/2012
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Provider Practice Location Address
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Address Line | 202 STATE ST SUITE A
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City | FORT SCOTT
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State | KS
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Zip | 66701-2031
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Country | US
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Telephone | 620-223-3950
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Fax |
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Provider Business Mailing Address
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Address Line | 202 STATE ST SUITE A
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City | FORT SCOTT
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State | KS
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Zip | 66701-2031
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Country | US
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Telephone | 620-223-3950
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. RICKY KELLENBERGER
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Credential | D.O
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Telephone | 620-224-3511
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 53-75555-122
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License Number State | KS
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