MEDICARE: BLAVO MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician

General Provider Information

NPI Number	:	1184575532
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAVO MEDICAL GROUP

Provider Business Mailing Address
First Line	:	3198 HIGHWAY 72 W
Second Line	:
City	:	CORINTH
State	:	MS
Zip	:	38834-9303
Country	:	US
Telephone Number	:	662-415-3242
Fax Number	:

Provider Business Practice Location Address
First Line	:	3198 HIGHWAY 72 W
Second Line	:
City	:	CORINTH
State	:	MS
Zip	:	38834-9303
Country	:	US
Telephone Number	:	662-415-3242
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. JASON E MCKELVEY
Credential	:
Telephone Number	:	662-415-3242

Provider Enumeration Date	:	02/03/2026
Last Update Date	:	02/03/2026

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