Provider Demographics
NPI:1841615754
Name:SANDBERG, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:CARMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:414-385-2301
Mailing Address - Fax:414-385-8791
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 145
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3624
Practice Address - Country:US
Practice Address - Phone:414-649-3240
Practice Address - Fax:414-649-3244
Is Sole Proprietor?:No
Enumeration Date:2014-02-28
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.150493208600000X
IDO-1388208600000X
WI23036208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100215196Medicaid