Provider Demographics
NPI:1316003114
Name:KENNETH G.PERRY JR., M.D P.A
Entity Type:Organization
Organization Name:KENNETH G.PERRY JR., M.D P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY ASSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-944-1717
Mailing Address - Street 1:PO BOX 24023
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 MARSHALL ST
Practice Address - Street 2:STE 505
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1651
Practice Address - Country:US
Practice Address - Phone:601-944-1717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10729207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02433841Medicaid
MS02433841Medicaid