Provider Demographics
NPI:1821589748
Name:KELUM, SIMON
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:KELUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4989 BRISTLE CONE CIR
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MD
Mailing Address - Zip Code:21001-2605
Mailing Address - Country:US
Mailing Address - Phone:301-237-2026
Mailing Address - Fax:
Practice Address - Street 1:4989 BRISTLE CONE CIR
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MD
Practice Address - Zip Code:21001-2605
Practice Address - Country:US
Practice Address - Phone:301-237-2026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-26
Last Update Date:2018-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR4244P163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health