Provider Demographics
NPI:1154326460
Name:HART, KELLY ZACH (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ZACH
Last Name:HART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 FOXRIDGE DR
Mailing Address - Street 2:STE 240
Mailing Address - City:MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66202-2338
Mailing Address - Country:US
Mailing Address - Phone:913-261-3153
Mailing Address - Fax:913-262-3295
Practice Address - Street 1:8929 PARALLEL PKWY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-1689
Practice Address - Country:US
Practice Address - Phone:913-596-4862
Practice Address - Fax:913-596-4635
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-165752085R0202X
MO20030079982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100200880BMedicaid
MO203568712Medicaid
MO203568712Medicaid
KS100200880BMedicaid
MOJ967045Medicare PIN
KSJ967045AMedicare PIN
MOJ967045BMedicare PIN