Provider Demographics
NPI:1760702815
Name:MCKELLAR, MARIAH MANN (MD)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:MANN
Last Name:MCKELLAR
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 1:303 GREEN ST E
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4105
Mailing Address - Country:US
Mailing Address - Phone:252-243-9800
Mailing Address - Fax:
Practice Address - Street 1:303 GREEN ST E
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4105
Practice Address - Country:US
Practice Address - Phone:252-243-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2013-00178208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC247301OtherMEDCOST
NCNCD002AOtherMEDICARE
NC18079OtherBCBS OF NC
NC1760702815Medicaid
NC1073315OtherUNITED HEALTH CARE
NC4802912OtherAETNA