Provider Demographics
NPI:1932163698
Name:KELLOGG, SCOTT KLEMENT (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:KLEMENT
Last Name:KELLOGG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-2687
Mailing Address - Country:US
Mailing Address - Phone:937-390-9665
Mailing Address - Fax:937-390-2363
Practice Address - Street 1:100 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2687
Practice Address - Country:US
Practice Address - Phone:937-390-9665
Practice Address - Fax:937-390-2363
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.005285207P00000X
OH34 005285207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000017758OtherANTHEM
OH0847169Medicaid
OH0847169Medicaid
OH000000017758OtherANTHEM
OHKE0703493Medicare PIN