North Delta Medicine Clinic P a

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

16776 Issued in MS

Legal business name

NORTH DELTA MEDICINE CLINIC P A

Practice address

705 N State St
Clarksdale, MS 38614-6519

Phone

(662) 621-2192

Fax

(662) 621-2314

NPI assigned

Oct 3, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Kenneth Wayne Kellough, M.D.

Title

Owner

Phone

(662) 621-2192

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159833600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1259798400000",
    "number": "1780778571",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1930",
            "city": "CLARKSDALE",
            "state": "MS",
            "postal_code": "386147930",
            "telephone_number": "662-621-2192",
            "fax_number": "662-621-2314"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "705 N STATE ST",
            "city": "CLARKSDALE",
            "state": "MS",
            "postal_code": "386146519",
            "telephone_number": "662-621-2192",
            "fax_number": "662-621-2314"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTH DELTA MEDICINE CLINIC P A",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-03",
        "last_updated": "2009-12-03",
        "status": "A",
        "authorized_official_last_name": "KELLOUGH",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "662-621-2192",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": "MS",
            "license": "16776",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01188776",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Internal Medicine Physician in Clarksdale, MS
• Providers in Clarksdale, MS by specialty
• Internal Medicine Physician in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 3, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.