Provider Demographics
NPI:1205120649
Name:ELEMENT PHYSICAL MEDICINE, LLC
Entity type:Organization
Organization Name:ELEMENT PHYSICAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:816-924-9475
Mailing Address - Street 1:PO BOX 16861
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-9998
Mailing Address - Country:US
Mailing Address - Phone:816-924-9475
Mailing Address - Fax:
Practice Address - Street 1:601 E. 63RD STREET
Practice Address - Street 2:SUITE 210
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64110-3303
Practice Address - Country:US
Practice Address - Phone:816-924-9475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010035953208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3360Medicare PIN