Provider Demographics
NPI:1124228754
Name:KELLUM, ROY BRADLEY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:BRADLEY
Last Name:KELLUM
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 30594
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28230-0594
Mailing Address - Country:US
Mailing Address - Phone:601-987-8200
Mailing Address - Fax:601-987-8211
Practice Address - Street 1:104 BURNEY DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6621
Practice Address - Country:US
Practice Address - Phone:601-987-8200
Practice Address - Fax:601-987-8211
Is Sole Proprietor?:No
Enumeration Date:2007-07-22
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS22081207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00753273Medicaid