Healthcare Provider Details

I. General information

NPI: 1073992160
Provider Name (Legal Business Name): KELLY DOREMUS PIPPIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST DEPARTMENT OF MEDICINE
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST DEPARTMENT OF MEDICINE
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5601
  • Fax: 601-984-6601
Mailing address:
  • Phone: 601-984-5601
  • Fax: 601-984-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number332909
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberT3000
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: