Provider Demographics
NPI:1356346449
Name:KELLAM, MARK E (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
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 1:1472 SOLUTIONS CTR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1004
Mailing Address - Country:US
Mailing Address - Phone:513-557-3333
Mailing Address - Fax:513-557-3332
Practice Address - Street 1:3131 QUEEN CITY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-2316
Practice Address - Country:US
Practice Address - Phone:513-557-3333
Practice Address - Fax:513-557-3332
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2008-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076218207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200237920Medicaid
OH2126907Medicaid
KY64963408Medicaid
OH9300765909Medicare PIN
OHG96792Medicare UPIN
KY64963408Medicaid