Provider Demographics
NPI:1700977121
Name:OSWALT, KENNETH E (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:OSWALT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5900
Mailing Address - Fax:601-984-5939
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5900
Practice Address - Fax:601-984-5939
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08785207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07726532Medicaid
MSP00232389OtherRAILROAD MEDICARE
MSP00604715 GRPDG7781OtherRAILROAD MEDICARE
MSP00232389OtherRAILROAD MEDICARE
MS050000764Medicare ID - Type Unspecified
MS512I050009Medicare PIN
MSP00604715 GRPDG7781OtherRAILROAD MEDICARE
MSE02483Medicare UPIN