Provider Demographics
NPI:1366472029
Name:KELLAM & ASSOCIATES, P. C.
Entity Type:Organization
Organization Name:KELLAM & ASSOCIATES, P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:TARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-667-5744
Mailing Address - Street 1:PO BOX 32627
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48232-0627
Mailing Address - Country:US
Mailing Address - Phone:866-744-1452
Mailing Address - Fax:586-412-4101
Practice Address - Street 1:1375 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1350
Practice Address - Country:US
Practice Address - Phone:810-667-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)Group - Single Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI300F361250OtherBCBS GROUP #
MICA3518OtherRR GROUP PIN
MICA3518OtherRR GROUP PIN
MI0D46002Medicare ID - Type UnspecifiedGROUP #