Healthcare Provider Details

I. General information

NPI: 1508929258
Provider Name (Legal Business Name): SAMUEL J KUYKENDALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2006
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 TROTWOOD AVE
COLUMBIA TN
38401-4886
US

IV. Provider business mailing address

1203 TROTWOOD AVE
COLUMBIA TN
38401-4886
US

V. Phone/Fax

Practice location:
  • Phone: 931-388-1181
  • Fax: 931-381-5302
Mailing address:
  • Phone: 931-388-1181
  • Fax: 931-381-5302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number621078139
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: