Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | 35.143319 | OH |
NPI | 1043745375 |
---|---|
Provider Name | Thomas Kellam |
First Address | Chillicothe, OH 45601-9031 |
Second Address | Chillicothe, OH 45601-9031 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2017 |
Last Update Date | 23/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0459528 | (05) | OH |