Provider Demographics
NPI:1932186681
Name:KELLENBERGER, RANDY (DO)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:KELLENBERGER
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 1:16410 RIGGS RD
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:KS
Mailing Address - Zip Code:66085-9128
Mailing Address - Country:US
Mailing Address - Phone:913-681-3217
Mailing Address - Fax:
Practice Address - Street 1:800 RAVENHILL DR
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-9204
Practice Address - Country:US
Practice Address - Phone:913-360-5320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9G92207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242720654Medicaid
C52006Medicare UPIN
MOP406948Medicare ID - Type Unspecified