Provider Demographics
NPI:1184732448
Name:HANCOCK FAMILY MEDICINE
Entity type:Organization
Organization Name:HANCOCK FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-586-9229
Mailing Address - Street 1:5400 INDIAN HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-3334
Mailing Address - Country:US
Mailing Address - Phone:228-586-9229
Mailing Address - Fax:228-586-9230
Practice Address - Street 1:5400 INDIAN HILL BLVD
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3334
Practice Address - Country:US
Practice Address - Phone:228-586-9229
Practice Address - Fax:228-586-9230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC93454OtherMEDICARE ID