Provider Demographics
NPI:1295763860
Name:KELLUM, WENDELL EVERETTE (MD)
Entity type:Individual
Prefix:
First Name:WENDELL
Middle Name:EVERETTE
Last Name:KELLUM
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 1:1030 NEW HOLLAND AVE
Mailing Address - Street 2:BLDG 12A SUITE 200
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-5690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 N DUKE ST
Practice Address - Street 2:FLOOR 1 WEST
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2250
Practice Address - Country:US
Practice Address - Phone:215-221-6633
Practice Address - Fax:215-221-5644
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH74727Medicare UPIN