MEDICARE: DR. JOHN HANSFORD KELLUM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	J0844	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255326989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN HANSFORD KELLUM M.D.

Provider Business Mailing Address
First Line	:	8920 US HIGHWAY 87 E
Second Line	:	STE.# 3
City	:	SAN ANTONIO
State	:	TX
Zip	:	78263-2238
Country	:	US
Telephone Number	:	210-648-0152
Fax Number	:	210-649-4170

Provider Business Practice Location Address
First Line	:	3903 WISEMAN BLVD
Second Line	:	SUITE 215
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-4401
Country	:	US
Telephone Number	:	210-675-6724
Fax Number	:	210-675-1759

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	11/21/2016

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