Provider Demographics
NPI:1679596613
Name:BISHOP, KELLEY (MD)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:BISHOP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-1000
Mailing Address - Fax:601-984-6811
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-1000
Practice Address - Fax:601-984-6811
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16770207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01245547OtherRAILROAD MEDICARE
MS302I080477OtherMEDICARE PTAN
MS0122139Medicaid
MSH07174Medicare UPIN
MS302I080477OtherMEDICARE PTAN
MS080003232Medicare ID - Type Unspecified
MS080003235Medicare ID - Type Unspecified
MS080003231Medicare ID - Type Unspecified
MS080003234Medicare ID - Type Unspecified
MS080003238Medicare ID - Type Unspecified
MS080003228Medicare ID - Type Unspecified
MSP01245547OtherRAILROAD MEDICARE
MS080003233Medicare ID - Type Unspecified
MS080003229Medicare ID - Type Unspecified