Basic Information
| Provider Information | |||||||||
| NPI: | 1629027776 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IAN A KELLMAN MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 246 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 186120246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709880925 | ||||||||
| FaxNumber: | 5709880919 | ||||||||
| Practice Location | |||||||||
| Address1: | 880 STATE RT. 6 W | ||||||||
| Address2: | TYLER MEM HOSP | ||||||||
| City: | TUNKHANNOCK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709880925 | ||||||||
| FaxNumber: | 5709880919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 07/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | KELLMAN | ||||||||
| AuthorizedOfficialFirstName: | IAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5709880925 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | CJ9716 | 01 | PA | RAIL ROAD MEDICARE | OTHER | 0018508240002 | 05 | PA | MEDICAID |