Healthcare Provider Details

I. General information

NPI: 1184732448
Provider Name (Legal Business Name): HANCOCK FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 INDIAN HILL BLVD
DIAMONDHEAD MS
39525-3334
US

IV. Provider business mailing address

5400 INDIAN HILL BLVD
DIAMONDHEAD MS
39525-3334
US

V. Phone/Fax

Practice location:
  • Phone: 228-586-9229
  • Fax: 228-586-9230
Mailing address:
  • Phone: 228-586-9229
  • Fax: 228-586-9230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RONALD KELLUM
Title or Position: MD OWNER
Credential: MD
Phone: 228-586-9229