Organization
DEATRICE L KELLOGG MD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DEATRICE LUMAE KELLOGG M.D. (OWNER)
(618) 257-2029
Entity
Organization
Contact information
Practice address
2661 N ILLINOIS ST, PMB 309, SWANSEA, IL 62226-2316
(618) 257-2029
(618) 235-5371
Mailing address
2661 N ILLINOIS ST, PMB 309, SWANSEA, IL 62226-2316
(618) 257-2029
(618) 235-5371
Taxonomy
Speciality
Code
Description
License number
State
207RG0300X
Geriatric Medicine (Internal Medicine) Physician
Primary
036097679
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
493905552
—
IL
01
—
DE5033
RR MEDICARE
—
Enumeration date
06/07/2006
Last updated
09/17/2008
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