Basic Information
| Provider Information | |||||||||
| NPI: | 1336633742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKELLAR | ||||||||
| FirstName: | DEXTER | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 LAFAYETTE AVE SE STE 4000 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166855922 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1175 WILSON AVE NW | ||||||||
| Address2: | |||||||||
| City: | WALKER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495346407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166858650 | ||||||||
| FaxNumber: | 6167912160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2018 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4351041142 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4301115644 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4301502149 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.