Healthcare Provider Details

I. General information

NPI: 1720544398
Provider Name (Legal Business Name): CAROL COUNTRYMAN KUTTEH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9250 GLENDA RD
GERMANTOWN TN
38139-6702
US

IV. Provider business mailing address

9250 GLENDA RD
GERMANTOWN TN
38139-6702
US

V. Phone/Fax

Practice location:
  • Phone: 901-752-5524
  • Fax: 901-747-4446
Mailing address:
  • Phone: 901-752-5524
  • Fax: 901-747-4446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number14353
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberJ0982
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number27764
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: