Provider Demographics
NPI:1205826641
Name:POMERENKE, KELLY SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:SCOTT
Last Name:POMERENKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 11TH ST
Mailing Address - Street 2:
Mailing Address - City:HAWARDEN
Mailing Address - State:IA
Mailing Address - Zip Code:51023-1903
Mailing Address - Country:US
Mailing Address - Phone:712-722-1882
Mailing Address - Fax:
Practice Address - Street 1:605 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CENTER
Practice Address - State:IA
Practice Address - Zip Code:51250-1347
Practice Address - Country:US
Practice Address - Phone:712-722-1271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27695207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1057729Medicaid
IAE48770Medicare UPIN
IA11890Medicare ID - Type Unspecified