Provider Demographics
NPI:1457380941
Name:KELLOGG, KEVIN ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ROBERT
Last Name:KELLOGG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 S BEAR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-2372
Mailing Address - Country:US
Mailing Address - Phone:231-563-6580
Mailing Address - Fax:231-563-6589
Practice Address - Street 1:72 S STATE ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MI
Practice Address - Zip Code:49455-1228
Practice Address - Country:US
Practice Address - Phone:231-861-3038
Practice Address - Fax:231-861-3082
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKK073336174400000X
MI43010733362084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1306101811OtherBCBS
MI3510652Medicaid
MI1306101811OtherBCBS
MI3510652Medicaid