Healthcare Provider Details

I. General information

NPI: 1619327848
Provider Name (Legal Business Name): KELSEY ELYCE KOCH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2016
Last Update Date: 11/15/2025
Certification Date: 11/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 657
JACKSON MS
39216-4608
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-2780
  • Fax: 601-200-2788
Mailing address:
  • Phone: 601-815-1331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR-10660
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number35449
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: