Basic Information
| Provider Information | |||||||||
| NPI: | 1184732448 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HANCOCK FAMILY MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 INDIAN HILL BLVD | ||||||||
| Address2: | |||||||||
| City: | DIAMONDHEAD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395253334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285869229 | ||||||||
| FaxNumber: | 2285869230 | ||||||||
| Practice Location | |||||||||
| Address1: | 5400 INDIAN HILL BLVD | ||||||||
| Address2: | |||||||||
| City: | DIAMONDHEAD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395253334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285869229 | ||||||||
| FaxNumber: | 2285869230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 11/26/2007 | ||||||||
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| AuthorizedOfficialLastName: | KELLUM | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2285869229 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | C93454 | 01 | MS | MEDICARE ID | OTHER |