Provider Demographics
NPI:1659405793
Name:EDWARDS, KENNY B (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNY
Middle Name:B
Last Name:EDWARDS
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 1:670 LEIGH DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705
Mailing Address - Country:US
Mailing Address - Phone:662-328-1012
Mailing Address - Fax:662-328-1507
Practice Address - Street 1:670 LEIGH DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705
Practice Address - Country:US
Practice Address - Phone:662-328-1012
Practice Address - Fax:662-328-1507
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21545207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00776741Medicaid
MS302I209082Medicare UPIN