Provider Demographics
NPI:1982648937
Name:KELLAM, D MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:D
Middle Name:MICHAEL
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 1:800 E 20TH ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3859
Mailing Address - Country:US
Mailing Address - Phone:307-634-7711
Mailing Address - Fax:
Practice Address - Street 1:800 E 20TH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3859
Practice Address - Country:US
Practice Address - Phone:307-634-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4219A2085R0202X
CO264582085R0202X
NE212642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY306010OtherBCBS OF WYOMING CRG
CO91042192Medicaid
WY104015400Medicaid
WY303602OtherBCBS OF WYOMING MRI
WY306010OtherBCBS OF WYOMING CRG
250002335Medicare ID - Type UnspecifiedRR MEDICARE MRI NUMBER
E16211Medicare UPIN
WY303602OtherBCBS OF WYOMING MRI
WY306010Medicare ID - Type UnspecifiedWY MEDICARE NUMBER
CO91042192Medicaid