Basic Information
| Provider Information | |||||||||
| NPI: | 1023058484 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEATRICE L KELLOGG MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2661 N ILLINOIS ST | ||||||||
| Address2: | PMB 309 | ||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622262316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182572029 | ||||||||
| FaxNumber: | 6182355371 | ||||||||
| Practice Location | |||||||||
| Address1: | 2661 N ILLINOIS ST | ||||||||
| Address2: | PMB 309 | ||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622262316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182572029 | ||||||||
| FaxNumber: | 6182355371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 09/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | KELLOGG | ||||||||
| AuthorizedOfficialFirstName: | DEATRICE | ||||||||
| AuthorizedOfficialMiddleName: | LUMAE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6182572029 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 036097679 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | DE5033 | 01 | RR MEDICARE | OTHER | 493905552 | 05 | IL | MEDICAID |