Provider Demographics
NPI:1336167725
Name:VICK, KENNETH DYLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DYLAN
Last Name:VICK
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 1:301 SAINT IVES DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7183
Mailing Address - Country:US
Mailing Address - Phone:601-853-8769
Mailing Address - Fax:
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:601-815-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18940208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01198277OtherRAILROAD MEDICARE PTAN
MS01220266Medicaid
MS302I025642Medicare PIN
MSP01198277OtherRAILROAD MEDICARE PTAN
MS020000538Medicare ID - Type Unspecified