Provider Demographics
NPI:1730268939
Name:KERBY, SEAN C (MD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:C
Last Name:KERBY
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:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-865-1453
Mailing Address - Fax:228-865-1457
Practice Address - Street 1:12261 HIGHWAY 49
Practice Address - Street 2:SUITE 11
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2975
Practice Address - Country:US
Practice Address - Phone:228-867-5185
Practice Address - Fax:228-867-5189
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34974207Q00000X
MS20062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07885561Medicaid
TNDE2565OtherRR MEDICARE GROUP
TN3861661Medicaid
TNP00344233OtherRR MEDICARE
TN4114136OtherBCBST
TN3732438Medicare ID - Type Unspecified
MS512I080277Medicare PIN
MSH22703Medicare UPIN
MS07885561Medicaid
TNP00344233OtherRR MEDICARE
MS302I115945Medicare PIN