# NORTH DELTA MEDICINE CLINIC P A

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1780778571
- **Authorized official:** DR. KENNETH WAYNE KELLOUGH M.D. (OWNER)
- **Authorized official phone:** (662) 621-2192

## Contact information

- **Practice address:** 705 N STATE ST, CLARKSDALE, MS 38614-6519
- **Practice address phone:** (662) 621-2192
- **Practice address fax:** (662) 621-2314
- **Mailing address:** PO BOX 1930, CLARKSDALE, MS 38614-7930
- **Mailing address phone:** (662) 621-2192
- **Mailing address fax:** (662) 621-2314

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | 16776 | MS | Yes |

## Other

- **Enumeration date:** 10/03/2006
- **Last updated:** 12/03/2009