Provider Demographics
NPI:1255601944
Name:FORT SCOTT FAMILY MEDICINE
Entity type:Organization
Organization Name:FORT SCOTT FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:620-224-3511
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-11
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-75555-122363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty