Provider Demographics
NPI:1649277831
Name:KEMM, RUSSELL RICHARD (DO)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:RICHARD
Last Name:KEMM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-2332
Mailing Address - Country:US
Mailing Address - Phone:417-667-3831
Mailing Address - Fax:417-667-4532
Practice Address - Street 1:216 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-2332
Practice Address - Country:US
Practice Address - Phone:417-667-3831
Practice Address - Fax:417-667-4532
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2D38207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241853324Medicaid
MO241853324Medicaid
D41502Medicare UPIN