Provider Demographics
NPI:1518381482
Name:KELLAM, ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:KELLAM
Suffix:
Gender:F
Credentials:PA
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 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:853 N CHURCH ST
Practice Address - Street 2:SUITE 720C
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3098
Practice Address - Country:US
Practice Address - Phone:864-560-6419
Practice Address - Fax:864-560-7498
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005328363A00000X
SCTL2484363A00000X
SC2484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2464PAMedicaid
SCSC74536066Medicare PIN