Provider Demographics
NPI:1467566802
Name:FORT SCOTT FAMILY MEDICINE, P.A.
Entity Type:Organization
Organization Name:FORT SCOTT FAMILY MEDICINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KELLENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:620-223-3950
Mailing Address - Street 1:202 STATE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT SCOTT
Mailing Address - State:KS
Mailing Address - Zip Code:66701-2031
Mailing Address - Country:US
Mailing Address - Phone:620-223-3950
Mailing Address - Fax:620-223-1302
Practice Address - Street 1:202 STATE ST
Practice Address - Street 2:SUITE A
Practice Address - City:FORT SCOTT
Practice Address - State:KS
Practice Address - Zip Code:66701-2031
Practice Address - Country:US
Practice Address - Phone:620-223-3950
Practice Address - Fax:620-223-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110645OtherBLUE CROSS BLUE SHIELD
KS2087370801Medicaid
KS110645Medicare ID - Type UnspecifiedMEDICARE