Provider Demographics
NPI:1790714954
Name:ASHLEY, KELLAN E (MD)
Entity Type:Individual
Prefix:
First Name:KELLAN
Middle Name:E
Last Name:ASHLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5678
Mailing Address - Fax:601-984-5638
Practice Address - Street 1:2500 N STATE STREET
Practice Address - Street 2:CARDIOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5678
Practice Address - Fax:601-984-5638
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.011859207RC0000X
MS18726207RC0000X, 207RI0011X
AL33296207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL130850Medicaid
MSP01233203OtherRAILROAD MEDICARE
MS04034504Medicaid
MSP01058840Medicare PIN
MSP01233203OtherRAILROAD MEDICARE
MS04034504Medicaid