Provider Demographics
NPI:1780778571
Name:NORTH DELTA MEDICINE CLINIC P A
Entity type:Organization
Organization Name:NORTH DELTA MEDICINE CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:KELLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-621-2192
Mailing Address - Street 1:PO BOX 1930
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-7930
Mailing Address - Country:US
Mailing Address - Phone:662-621-2192
Mailing Address - Fax:662-621-2314
Practice Address - Street 1:705 N STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6519
Practice Address - Country:US
Practice Address - Phone:662-621-2192
Practice Address - Fax:662-621-2314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16776207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01188776Medicaid