Provider Demographics
NPI:1164599387
Name:KELLUM, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:KELLUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W9675 HOMBURG LN
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-3702
Mailing Address - Country:US
Mailing Address - Phone:262-473-0961
Mailing Address - Fax:
Practice Address - Street 1:W9575 HOMBURG LANE
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190
Practice Address - Country:US
Practice Address - Phone:262-473-0961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36138-020207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32082900Medicaid
WI541760308Medicare PIN
WIKELLUMICOtherMERYCCARE INSURANCE
IL036068853 1Medicaid
C42917Medicare UPIN