Basic Information
| Provider Information | |||||||||
| NPI: | 1346546306 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KEMPER CAH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JOHN C STENNIS PROFESSIONAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1314 19TH AVE | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017039393 | ||||||||
| FaxNumber: | 6017033080 | ||||||||
| Practice Location | |||||||||
| Address1: | 14365 HIGHWAY 16 W | ||||||||
| Address2: | |||||||||
| City: | DE KALB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393287974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7694861000 | ||||||||
| FaxNumber: | 7694861090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2011 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
| AuthorizedOfficialMiddleName: | LARKIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6017039614 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 09653506 | 05 | MS | MEDICAID |