MEDICARE: KENNETH KAISER NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	R856338	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	202011213A	OTHER	MS	BLUE CROSS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073557039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH KAISER NP

Provider Business Mailing Address
First Line	:	11 PROFESSIONAL PKWY
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-4113
Country	:	US
Telephone Number	:	601-856-2460
Fax Number	:	601-856-4687

Provider Business Practice Location Address
First Line	:	11 PROFESSIONAL PKWY
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-4113
Country	:	US
Telephone Number	:	601-856-2460
Fax Number	:	601-856-4687

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	02/25/2011

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