Provider Demographics
NPI:1588636823
Name:HARTEL, KELLY L (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:HARTEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11421 S STATE HIGHWAY 21
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-3091
Mailing Address - Country:US
Mailing Address - Phone:573-210-6564
Mailing Address - Fax:
Practice Address - Street 1:1101 W. LIBERTY
Practice Address - Street 2:PARKLAND HEALTH CENTER
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640
Practice Address - Country:US
Practice Address - Phone:573-760-8475
Practice Address - Fax:573-760-8484
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111596207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208854604Medicaid
MO964293210Medicare PIN
MOG40050Medicare UPIN
MO208854604Medicaid
MO005012288Medicare ID - Type UnspecifiedMISSOURI MEDICARE