Basic Information
| Provider Information | |||||||||
| NPI: | 1831160647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKELLAR | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBERTS | ||||||||
| OtherFirstName: | HEIDI | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146458525 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2201 INWOOD RD 2ND FLOOR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753901806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146454673 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0002X | J8740 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 2085R0001X | J8740 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085H0002X | J8740 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0007363100 | 01 | AETNA | OTHER | 148500501 | 05 | TX | MEDICAID | 920006629 | 01 | RR MEDICARE | OTHER | 83271G | 01 | TX | BCBS | OTHER |