Provider Demographics
NPI:1104909274
Name:WHALLEY, KEVIN M (MD)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:WHALLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:965 JK AVENT DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901
Mailing Address - Country:US
Mailing Address - Phone:662-226-4088
Mailing Address - Fax:662-226-0198
Practice Address - Street 1:965 JK AVENT DR
Practice Address - Street 2:SUITE 103
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901
Practice Address - Country:US
Practice Address - Phone:662-226-4088
Practice Address - Fax:662-226-0198
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS14578207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115400Medicaid
F28555Medicare UPIN
MS200000223Medicare PIN