MEDICARE: KELLY J. LOGAN D.O.

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
2	208100000X	Physical Medicine & Rehabilitation Physician	0533193	KS
3	208100000X	Physical Medicine & Rehabilitation Physician	48544	WI

General Provider Information

NPI Number	:	1376592139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY J. LOGAN D.O.

Provider Business Mailing Address
First Line	:	601 E 63RD ST STE 210
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64110-3303
Country	:	US
Telephone Number	:	816-569-5475
Fax Number	:	816-569-5482

Provider Business Practice Location Address
First Line	:	601 E 63RD ST STE 210
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64110-3303
Country	:	US
Telephone Number	:	816-569-5475
Fax Number	:	816-569-5482

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	04/20/2021

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Directions to “ KELLY J. LOGAN D.O.” Practice Location

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