Healthcare Provider Details

I. General information

NPI: 1366472029
Provider Name (Legal Business Name): KELLAM & ASSOCIATES, P. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 N MAIN ST
LAPEER MI
48446-1350
US

IV. Provider business mailing address

PO BOX 32627
DETROIT MI
48232-0627
US

V. Phone/Fax

Practice location:
  • Phone: 810-667-5500
  • Fax:
Mailing address:
  • Phone: 866-744-1452
  • Fax: 586-412-4101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KENNETH TARR
Title or Position: PRESIDENT
Credential:
Phone: 810-667-5744