Healthcare Provider Details

I. General information

NPI: 1548261191
Provider Name (Legal Business Name): KENNETH REED GRAVETT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2005
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 WASHINGTON ST
SHELBYVILLE KY
40065-1129
US

IV. Provider business mailing address

517 WASHINGTON ST
SHELBYVILLE KY
40065-1129
US

V. Phone/Fax

Practice location:
  • Phone: 502-633-0120
  • Fax: 502-633-0882
Mailing address:
  • Phone: 502-633-0120
  • Fax: 502-633-0882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02078
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: