Provider Demographics
NPI:1750305595
Name:KELLAM, LORI GOCO (MD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:GOCO
Last Name:KELLAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:ANN-GOCO
Other - Last Name:KELLAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2825 LYNDHURST AVE STE 101
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4146
Practice Address - Country:US
Practice Address - Phone:336-277-6300
Practice Address - Fax:336-277-6309
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600966208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8948204Medicaid
NC48204OtherBCBS OF NC
NC8948204Medicaid
NC2224338AMedicare PIN
NC48204OtherBCBS OF NC