Ronald Fulton Kellum, M.D.
Individual provider Active NPI Family Medicine Physician · Diamondhead, MS
NPI 1679543102 · NPPES record last updated Jan 23, 2014
Key facts
- NPI
- 1679543102
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 19011 (MS)
- Practice address
- 4433 Leisure Time
Diamondhead, MS 39525-3259 - Phone
- (228) 586-9229
- Fax
- (228) 586-9230
- NPI assigned
- Jan 26, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 4
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20060301000311 | MS | Practitioner - Family Practice | 6901812973 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Memorial Hospital at Gulfport | Current |
Accepting new patients | |
| Memorial Hospital at Gulfport | Current | Accepting new patients | |
| Hancock Medical Health Services, Inc. | Past |
Accepting new patients |
Locations
4433 Leisure Time Dr
Diamondhead, MS 39525
Phone (228) 575-2848
4433 Leisure Time Dr
Unit C
Diamondhead, MS 39525
4500 13th St
Gulfport, MS 39501
Phone (228) 236-3872
1340 Broad Ave
Ste 440
Gulfport, MS 39501
Phone (228) 867-4856
Interoperability endpoints
- rkellum@direct.mhg.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 19011 | MS | Yes |
Addresses
Primary practice location
4433 Leisure Time
Diamondhead, MS 39525-3259
Mailing address
149 Drinkwater Rd
Bay St Louis, MS 39520-1658
Phone (228) 467-8676
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 19011 | Other | MS | MISSISSIPPI LICENSE |
Other providers in Diamondhead, MS
- Preethi S Harrison
- Allison Kae Hennessey
- Desmond Wayne Hoda
- John Cameron Hodge
- Kenneth Edward Hultman
- Deedy Killen
- Micah Anthony Ladner
- Brittany Michelle Lander
- Love'S Pharmacy No 2, Inc
- Love'S Pharmacy No 2, Inc
All providers in Diamondhead, MS · Family Medicine Physician in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 23, 2014. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.