Provider Demographics
NPI:1992708564
Name:GOEB, KELLY J (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:J
Last Name:GOEB
Suffix:
Gender:F
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:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:MN
Mailing Address - Zip Code:55726-0116
Mailing Address - Country:US
Mailing Address - Phone:320-245-2250
Mailing Address - Fax:320-245-2555
Practice Address - Street 1:5565 HIGHWAY 210
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:MN
Practice Address - Zip Code:55726-8171
Practice Address - Country:US
Practice Address - Phone:320-245-2250
Practice Address - Fax:320-245-2555
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40702207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN695715300Medicaid
MNG75490Medicare UPIN
MN695715300Medicaid