Provider Demographics
NPI:1700864568
Name:KELLENBERGER, RICKY (DO)
Entity Type:Individual
Prefix:DR
First Name:RICKY
Middle Name:
Last Name:KELLENBERGER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 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
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000157954207P00000X
KS05-19720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO245111802Medicaid
A02084Medicare UPIN
MOP40A786Medicare ID - Type Unspecified