Basic Information
| Provider Information | |||||||||
| NPI: | 1811151202 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KELLAM & ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4420 VARSITY DR | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481082233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346777400 | ||||||||
| FaxNumber: | 7346777407 | ||||||||
| Practice Location | |||||||||
| Address1: | 399 S BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | LAKE ORION | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483622740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483385604 | ||||||||
| FaxNumber: | 2483385605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2008 | ||||||||
| LastUpdateDate: | 12/14/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/22/2009 | ||||||||
| NPIReactivationDate: | 10/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | LUM | ||||||||
| AuthorizedOfficialFirstName: | LEIGHTON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7346777400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 208VP0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.