Provider Demographics
NPI:1376592139
Name:LOGAN, KELLY J (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:LOGAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E 63RD ST STE 210
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64110-3303
Mailing Address - Country:US
Mailing Address - Phone:816-569-5475
Mailing Address - Fax:816-569-5482
Practice Address - Street 1:601 E 63RD ST STE 210
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64110-3303
Practice Address - Country:US
Practice Address - Phone:816-569-5475
Practice Address - Fax:816-569-5482
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010035953208100000X
KS0533193208100000X
WI48544208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3360001Medicare PIN