Provider Demographics
NPI:1497740641
Name:KELLAM, MARILYN S (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:S
Last Name:KELLAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 KINGSLEY LN
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4614
Mailing Address - Country:US
Mailing Address - Phone:757-345-2885
Mailing Address - Fax:
Practice Address - Street 1:110 KINGSLEY LN
Practice Address - Street 2:SUITE 302
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4614
Practice Address - Country:US
Practice Address - Phone:757-345-2885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036061207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV0556AMedicare PIN
B07197Medicare UPIN
VA1497740641Medicaid
VAP00918165Medicare PIN