Provider Demographics
NPI:1275733073
Name:KELLENBERGER, BRYAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:KELLENBERGER
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 1:1025 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2403
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:217-525-0044
Practice Address - Street 1:400 SAINT JOHNS DR
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:IL
Practice Address - Zip Code:62684-9779
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:217-525-0044
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036125353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036125353Medicaid
ILP00912560OtherRAILROAD MEDICARE
IL635800002Medicare PIN
IL9015656OtherBCBS