MEDICARE: ELEMENT PHYSICAL MEDICINE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	2010035953	MO

General Provider Information

NPI Number	:	1205120649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEMENT PHYSICAL MEDICINE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 16861
Second Line	:
City	:	RAYTOWN
State	:	MO
Zip	:	64133-9998
Country	:	US
Telephone Number	:	816-924-9475
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 E. 63RD STREET
Second Line	:	SUITE 210
City	:	KANSAS CITY
State	:	MO
Zip	:	64110-3303
Country	:	US
Telephone Number	:	816-924-9475
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KELLY J LOGAN
Credential	:	DO
Telephone Number	:	816-924-9475

Provider Enumeration Date	:	06/02/2011
Last Update Date	:	05/05/2016

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