Basic Information
| Provider Information | |||||||||
| NPI: | 1306869102 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAIN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | BRENT | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23666 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004749 | ||||||||
| FaxNumber: | 6012005929 | ||||||||
| Practice Location | |||||||||
| Address1: | 342 MAGNOLIA DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391536012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017825665 | ||||||||
| FaxNumber: | 6017825857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 09/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 16442 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00123546 | 05 | MS | MEDICAID |