Provider Demographics
NPI:1508836032
Name:KELLUM, KENNETH M (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
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 1:1542 MEDICAL PARK CIR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6560
Mailing Address - Country:US
Mailing Address - Phone:662-844-4711
Mailing Address - Fax:662-844-9619
Practice Address - Street 1:1542 MEDICAL PARK CIR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6560
Practice Address - Country:US
Practice Address - Phone:662-844-4711
Practice Address - Fax:662-844-9619
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17130207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
73005462OtherBLUE CROSS BLUE SHIELD
17130OtherSTATE LIC NUMBER
0052650OtherBLUE CROSS BLUE SHIELD
AL009970180Medicaid
MS00124083Medicaid
73005462OtherBLUE CROSS BLUE SHIELD
MS00124083Medicaid
H35039Medicare UPIN
MS390000113Medicare PIN
AL051555843Medicare PIN