Provider Demographics
NPI:1689789950
Name:KELLAM, MICHAEL PAUL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAUL
Last Name:KELLAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4708 ALLIANCE BLVD STE 550
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5363
Mailing Address - Country:US
Mailing Address - Phone:972-758-6000
Mailing Address - Fax:972-758-6001
Practice Address - Street 1:4708 ALLIANCE BLVD STE 550
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5363
Practice Address - Country:US
Practice Address - Phone:972-758-6000
Practice Address - Fax:972-758-6001
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL74452084N0400X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1649154-01Medicaid
TX8F4614OtherBCBS
TXI04981Medicare UPIN
TX8B9607Medicare PIN
TX8F4614OtherBCBS
TX8B6843Medicare PIN