Provider Demographics
NPI:1992894372
Name:KELLUM, REBECCA I (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:I
Last Name:KELLUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 GAMMON LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-2210
Mailing Address - Country:US
Mailing Address - Phone:608-417-8144
Mailing Address - Fax:
Practice Address - Street 1:1015 GAMMON LN
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-2210
Practice Address - Country:US
Practice Address - Phone:608-417-8144
Practice Address - Fax:608-260-6451
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49401-020207RA0401X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1992894372Medicaid
WI1992894372Medicaid