Basic Information
| Provider Information | |||||||||
| NPI: | 1457098154 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLOGG | ||||||||
| FirstName: | CLARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5910 BLUESTONE WAY | ||||||||
| Address2: | |||||||||
| City: | LEWIS CENTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430357550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143012639 | ||||||||
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| Practice Location | |||||||||
| Address1: | 799 LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449071906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197565133 | ||||||||
| FaxNumber: | 4197749707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2022 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.