MEDICARE: DEATRICE LUMAE KELLOGG MD

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	207Q00000X	Family Medicine Physician	2012030150	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00302605	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7300116	OTHER		UHC
2	191723	OTHER		GHP

General Provider Information

NPI Number	:	1528007416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEATRICE LUMAE KELLOGG MD

Provider Business Mailing Address
First Line	:	4457 S FARM ROAD 145
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65810-1414
Country	:	US
Telephone Number	:	417-830-4701
Fax Number	:

Provider Business Practice Location Address
First Line	:	4457 S FARM ROAD 145
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65810-1414
Country	:	US
Telephone Number	:	417-830-4701
Fax Number	:

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

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	06/04/2024

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