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NPI Code Detail

MEDICARE: KELLEY G KELLOGG DO

MEDICARE: KELLEY G KELLOGG DO
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
1207R00000XInternal Medicine PhysicianL8497TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
38S2471OTHERTXBCBS

General Provider Information

NPI Number : 1487685194
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLEY G KELLOGG DO
Provider Business Mailing Address
First Line : 10864 TEXAS HEALTH TRL
Second Line :
City : FORT WORTH
State : TX
Zip : 76244-4897
Country : US
Telephone Number : 682-212-3160
Fax Number : 682-212-9301
Provider Business Practice Location Address
First Line : 10864 TEXAS HEALTH TRL
Second Line :
City : FORT WORTH
State : TX
Zip : 76244-4897
Country : US
Telephone Number : 682-212-3160
Fax Number : 682-212-9301
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/05/2006
Last Update Date : 04/04/2022

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