Healthcare Provider Details

I. General information

NPI: 1295905891
Provider Name (Legal Business Name): KENNETH BRIAN BOYD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 BAPTIST BLVD STE 407
COLUMBUS MS
39705-2004
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 662-241-4223
  • Fax: 662-241-4460
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25409
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: