Provider Demographics
NPI:1932130127
Name:KERUT, TIMOTHY P (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:KERUT
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 1:104 MCAULEY DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-2825
Mailing Address - Country:US
Mailing Address - Phone:601-638-7271
Mailing Address - Fax:
Practice Address - Street 1:2200 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8246
Practice Address - Country:US
Practice Address - Phone:601-883-3320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11047207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120441Medicaid
MS5694020OtherAETNA
LA1546143Medicaid
LA1546143Medicaid
MS00120441Medicaid
MS030000028Medicare PIN
MS370018119Medicare PIN