Provider Demographics
NPI:1427028638
Name:SHRUM, KELLY DEAN (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DEAN
Last Name:SHRUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638-0509
Mailing Address - Country:US
Mailing Address - Phone:870-538-5414
Mailing Address - Fax:870-538-5412
Practice Address - Street 1:535 JORDAN DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5714
Practice Address - Country:US
Practice Address - Phone:870-367-6246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0704207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR18424000000OtherQUALCHOICE
AR136791003Medicaid
AR18424000000OtherQUALCHOICE
G22323Medicare UPIN