Provider Demographics
NPI:1023088382
Name:KELLMAN, IAN A (MD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:A
Last Name:KELLMAN
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 1:625 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:SHAVERTON
Mailing Address - State:PA
Mailing Address - Zip Code:18708-9526
Mailing Address - Country:US
Mailing Address - Phone:570-881-3354
Mailing Address - Fax:570-696-0174
Practice Address - Street 1:625 HAMPTON RD
Practice Address - Street 2:
Practice Address - City:SHAVERTON
Practice Address - State:PA
Practice Address - Zip Code:18708-9526
Practice Address - Country:US
Practice Address - Phone:570-881-3354
Practice Address - Fax:570-696-0174
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017470E2085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006544430001Medicaid
PAB36924Medicare UPIN
PA0006544430001Medicaid