Provider Demographics
NPI:1245228980
Name:KLAMATH FA MILY PRACTICE CENTER PC
Entity Type:Organization
Organization Name:KLAMATH FA MILY PRACTICE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCKELLAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-238-6462
Mailing Address - Street 1:PO BOX 5234
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-0203
Mailing Address - Country:US
Mailing Address - Phone:541-238-6462
Mailing Address - Fax:541-539-6439
Practice Address - Street 1:2310 MOUNTAIN VIEW BLVD
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1134
Practice Address - Country:US
Practice Address - Phone:541-238-6432
Practice Address - Fax:541-539-6439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR=========OtherFEDERAL TAX ID #
ORR0000WCHTWMedicare PIN
OR0761880001Medicare NSC