Provider Demographics
NPI:1831157114
Name:FEHRENBACHER, KELLY JANELL (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JANELL
Last Name:FEHRENBACHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:1111 W WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-2233
Practice Address - Country:US
Practice Address - Phone:608-269-6731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48684207RH0002X, 207RH0002X
WI48684-20207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIFEHREKELOtherMERCYCARE INSURANCE
WI1831157114OtherBCBSWI
WI1831157114Medicaid
WI1831157114OtherBCBSWI
WI541760920Medicare PIN