Individual
D MICHAEL KELLAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
800 E 20TH ST, SUITE 110, CHEYENNE, WY 82001-3859
(307) 634-7711
Mailing address
800 E 20TH ST, SUITE 110, CHEYENNE, WY 82001-3859
(307) 634-7711
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
21264
NE
2085R0202X
Diagnostic Radiology Physician
26458
CO
2085R0202X
Diagnostic Radiology Physician
Primary
4219A
WY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
104015400
—
WY
01
—
303602
BCBS OF WYOMING MRI
WY
01
—
306010
BCBS OF WYOMING CRG
WY
05
—
91042192
—
CO
Enumeration date
06/16/2006
Last updated
07/09/2007
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