Provider Demographics
NPI:1255043089
Name:KELLUM, WALLACE T
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:T
Last Name:KELLUM
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 1:5949 S ABERDEEN ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-1429
Mailing Address - Country:US
Mailing Address - Phone:773-556-9732
Mailing Address - Fax:
Practice Address - Street 1:5949 S ABERDEEN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-1429
Practice Address - Country:US
Practice Address - Phone:773-556-9732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-26
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILCG83801172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty