| North Delta Medicine Clinic P A | |
|
705 N State St Clarksdale MS 38614-6519 | |
| (662) 621-2192 | |
| (662) 621-2314 |
| Full Name | North Delta Medicine Clinic P A |
|---|---|
| Speciality | Internal Medicine |
| Location | 705 N State St, Clarksdale, Mississippi |
| Authorized Official Name and Position | Kenneth Wayne Kellough (OWNER) |
| Authorized Official Contact | 6626212192 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| North Delta Medicine Clinic P A Po Box 1930 Clarksdale MS 38614-7930 Ph: (662) 621-2192 | North Delta Medicine Clinic P A 705 N State St Clarksdale MS 38614-6519 Ph: (662) 621-2192 |
| NPI Number | 1780778571 |
|---|---|
| Provider Enumeration Date | 10/03/2006 |
| Last Update Date | 12/03/2009 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1780778571 | NPI | - | NPPES |
| 01188776 | Medicaid | MS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | 16776 (Mississippi) | Primary |
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