Provider Demographics
NPI:1821082751
Name:KRUG, KELLEY A (PA C)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:A
Last Name:KRUG
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:A
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA C
Mailing Address - Street 1:3375 N SEMINARY ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-1251
Mailing Address - Country:US
Mailing Address - Phone:309-343-5114
Mailing Address - Fax:
Practice Address - Street 1:3375 N SEMINARY ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1251
Practice Address - Country:US
Practice Address - Phone:309-343-5114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK27256Medicare ID - Type UnspecifiedMEDICARE ID #
ILP00326114Medicare ID - Type UnspecifiedRR INDIVIDUAL
IL210745Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILK18591Medicare ID - Type Unspecified
ILCB6569Medicare ID - Type UnspecifiedRR GROUP #
S56631Medicare UPIN