Basic Information
| Provider Information | |||||||||
| NPI: | 1457765133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KALLENBERGER | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3130 E 26TH PL | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741144314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189069110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1010 N KANSAS ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162932665 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2014 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 9408339 | KS | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 6682 | OK | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.