Healthcare Provider Details

I. General information

NPI: 1043745375
Provider Name (Legal Business Name): THOMAS CLARK KELLAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ROBINHOOD MEDICAL PLZ
WINSTON SALEM NC
27106-5471
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-718-7950
  • Fax: 336-718-7989
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2025-02829
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35.143319
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2025-02829
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: