Provider Demographics
NPI:1306869102
Name:CAIN, KENNETH BRENT (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:BRENT
Last Name:CAIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4749
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:342 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:MS
Practice Address - Zip Code:39153-6012
Practice Address - Country:US
Practice Address - Phone:601-782-5665
Practice Address - Fax:601-782-5857
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16442207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123546Medicaid
MS352379YJ9XMedicare PIN
MSH29901Medicare UPIN
MS080003380Medicare ID - Type Unspecified
MS080003378Medicare ID - Type Unspecified
MS080003384Medicare ID - Type Unspecified
MS00123546Medicaid
MS080003386Medicare ID - Type Unspecified
MS080003382Medicare ID - Type Unspecified
MS080003383Medicare ID - Type Unspecified
MS080003403Medicare ID - Type Unspecified
MS080003379Medicare ID - Type Unspecified
MS080003385Medicare ID - Type Unspecified