Provider Demographics
NPI:1609815000
Name:KELLOUGH, KENNETH W (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:KELLOUGH
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 1:705 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6519
Mailing Address - Country:US
Mailing Address - Phone:662-621-2192
Mailing Address - Fax:662-621-2314
Practice Address - Street 1:705 N STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6519
Practice Address - Country:US
Practice Address - Phone:662-621-2192
Practice Address - Fax:662-621-2314
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16776207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121009Medicaid
G95515Medicare UPIN
MS00121009Medicaid