Basic Information
| Provider Information | |||||||||
| NPI: | 1790871895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADKISSON | ||||||||
| FirstName: | KENDRAL | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ADKISSON | ||||||||
| OtherFirstName: | K | ||||||||
| OtherMiddleName: | WAYNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4828 N DAVIS HWY | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504778109 | ||||||||
| FaxNumber: | 8504782412 | ||||||||
| Practice Location | |||||||||
| Address1: | 5147 N 9TH AVE STE 311 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504772597 | ||||||||
| FaxNumber: | 8504787941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 04/11/2018 | ||||||||
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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 | 207RG0100X | ME82477 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 002102707001 | 01 | UNITED HEATLH CARE | OTHER | B336 | 01 | HEALTH OPTIONS | OTHER | 059039702 | 01 | AL | BCBS OF ALABAMA | OTHER | 7192252 | 01 | AETNA | OTHER | 261558400 | 05 | FL | MEDICAID | 009957930 | 05 | AL | MEDICAID | 26083 | 01 | FL | BCBS OF FLORIDA | OTHER | 100015381 | 01 | RAILROAD MEDICARE | OTHER | 8242665 | 01 | CIGNA | OTHER |