NPIMap

Individual provider Active NPI

Kellan Fitzgerald Clark, DO

  • Urology Physician
  • Hamilton, MT
National Provider Identifier
1134539091
Registry record updated Nov 12, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Urology PhysicianTaxonomy code 208800000X
License
MED-PHYS-LIC-71931 Issued in MT
Practice address
1200 Westwood Dr Ste F
Hamilton, MT 59840-2345
Phone
(406) 375-2930
Fax
(406) 375-4525
NPI assigned
Apr 30, 2014
Last updated
Nov 12, 2024By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 12, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Urology Physician 208800000X MED-PHYS-LIC-71931 MT Primary

Addresses

Primary practice location

1200 Westwood Dr Ste F
Hamilton, MT 59840-2345

Mailing address

1200 Westwood Dr
Hamilton, MT 59840-2345

Other identifiers 2

IdentifierTypeStateIssuer
1134539091MedicaidID
100004016MedicaidMT

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL KELLANCLARKMDMHCERNERDIRECTCOM

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MT
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20191016000294 MT Practitioner - Urology 1850642497 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Urology
Education
Edward Via Col of Osteo Medicine-Carolinas Campus, 2014
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

3975 US Hwy 93 N
Stevensville, MT 59870-6474
Phone (406) 777-6002

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

Practice roles

OrganizationSpecialtyStatusNew patients
Marcus Daly Memorial Hospital Corp CurrentSince Nov 17, 2024 Accepting new patients
Marcus Daly Memorial Hospital Corporation CurrentSince Jul 22, 2019 Accepting new patients
Marcus Daly Memorial Hospital Corporation Current Accepting new patients

Locations

1200 Westwood Dr
Hamilton, MT 59840
Phone (406) 363-2211

1200 Westwood Dr
Ste F
Hamilton, MT 59840
Phone (406) 375-2930

1224 W Main St
Hamilton, MT 59840
Phone (406) 375-4823

215 N 10th St
Ste A
Hamilton, MT 59840
Phone (406) 363-2421

3975 US Highway 93 N
Stevensville, MT 59870
Phone (406) 375-4824

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1398816000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1731369600000",
    "number": "1134539091",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 WESTWOOD DR",
            "city": "HAMILTON",
            "state": "MT",
            "postal_code": "598402345"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1200 WESTWOOD DR STE F",
            "city": "HAMILTON",
            "state": "MT",
            "postal_code": "598402345",
            "telephone_number": "406-375-2930",
            "fax_number": "406-375-4525"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "KELLAN",
        "middle_name": "FITZGERALD",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-04-30",
        "last_updated": "2024-11-12",
        "certification_date": "2024-11-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208800000X",
            "taxonomy_group": "",
            "desc": "Urology",
            "state": "MT",
            "license": "MED-PHYS-LIC-71931",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1134539091",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100004016",
            "state": "MT"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "KELLANCLARKMDMHCERNERDIRECTCOM",
            "affiliation": "N",
            "address_1": "1200 Westwood Dr Ste F",
            "city": "Hamilton",
            "state": "MT",
            "country_code": "US",
            "postal_code": "598402345",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Hamilton, MT

Sources for this page

Verify at the official NPI Registry.