Provider Demographics
NPI:1871023093
Name:ADEBISI, KEHINDE ADEWALE (MD)
Entity Type:Individual
Prefix:DR
First Name:KEHINDE
Middle Name:ADEWALE
Last Name:ADEBISI
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 1:504 CLINTON CENTER DRIVE
Mailing Address - Street 2:CBO - SUITE 4300
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056
Mailing Address - Country:US
Mailing Address - Phone:601-496-9794
Mailing Address - Fax:601-815-0434
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS27822208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS27822OtherMSBML