Basic Information
| Provider Information | |||||||||
| NPI: | 1699092056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELAY | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | JACKSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 CENTER ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319011575 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1538 13TH AVE STE A | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319012544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063234000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2010 | ||||||||
| LastUpdateDate: | 11/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | ME132919 | FL | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 301759 | LA | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 86376 | GA | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 86892 | SC | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.