Provider Demographics
NPI:1770565798
Name:REID, KENNETH J JR (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:REID
Suffix:JR
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:PO BOX 5183
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5183
Mailing Address - Country:US
Mailing Address - Phone:601-703-9506
Mailing Address - Fax:601-703-3264
Practice Address - Street 1:1710 14TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4140
Practice Address - Country:US
Practice Address - Phone:601-482-9211
Practice Address - Fax:601-482-9497
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09031208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115342Medicaid
731-01758OtherBLUE CROSS OF AL
B64575Medicare UPIN