Healthcare Provider Details

I. General information

NPI: 1487666228
Provider Name (Legal Business Name): KHEDER KUTMAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 BANKERS ST
FLORENCE KY
41042-4212
US

IV. Provider business mailing address

PO BOX 304
FLORENCE KY
41022-0304
US

V. Phone/Fax

Practice location:
  • Phone: 859-992-4660
  • Fax:
Mailing address:
  • Phone: 859-992-4660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35543
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number35543
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number35543
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: