Healthcare Provider Details

I. General information

NPI: 1609141811
Provider Name (Legal Business Name): VALIPARAMBIL BALAKRISHNAN PRAVEEN KUMAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 05/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 AVENT DR
GRENADA MS
38901-5230
US

IV. Provider business mailing address

960 AVENT DR
GRENADA MS
38901-5230
US

V. Phone/Fax

Practice location:
  • Phone: 662-227-7008
  • Fax:
Mailing address:
  • Phone: 662-227-7008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPT 12243
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number23517
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number23517
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: