Healthcare Provider Details

I. General information

NPI: 1992894372
Provider Name (Legal Business Name): REBECCA I KELLUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 W WASHINGTON AVE STE 100
MADISON WI
53703-2996
US

IV. Provider business mailing address

202 S PARK ST
MADISON WI
53715-1507
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-8300
  • Fax: 608-417-8301
Mailing address:
  • Phone: 608-417-6000
  • Fax: 608-417-3878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number49401-020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number49401-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: