Provider Demographics
NPI:1629027776
Name:IAN A KELLMAN MD LLC
Entity Type:Organization
Organization Name:IAN A KELLMAN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-988-0925
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-0246
Mailing Address - Country:US
Mailing Address - Phone:570-988-0925
Mailing Address - Fax:570-988-0919
Practice Address - Street 1:880 STATE RT. 6 W
Practice Address - Street 2:TYLER MEM HOSP
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657
Practice Address - Country:US
Practice Address - Phone:570-988-0925
Practice Address - Fax:570-988-0919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACJ9716OtherRAIL ROAD MEDICARE
PA0018508240002Medicaid
PA0018508240002Medicaid