Provider Demographics
NPI:1427055185
Name:KELLUM, ANDREW H (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:H
Last Name:KELLUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:961 SOUTH GLOSTER STREET
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801
Mailing Address - Country:US
Mailing Address - Phone:662-844-9166
Mailing Address - Fax:
Practice Address - Street 1:961 SOUTH GLOSTER STREET
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801
Practice Address - Country:US
Practice Address - Phone:662-844-9166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10045207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0011168Medicaid
MS0685410004Medicare NSC
MS0685410003Medicare NSC
MS0685410002Medicare NSC
MS110000386Medicare PIN
MSE01529Medicare UPIN
MS0011168Medicaid