Healthcare Provider Details

I. General information

NPI: 1225027014
Provider Name (Legal Business Name): PAUL EDWARD KUDELKO II DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 02/01/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 NEW SHACKLE ISLAND RD SUITE 300C
HENDERSONVILLE TN
37075-2379
US

IV. Provider business mailing address

353 NEW SHACKLE ISLAND RD SUITE 300C
HENDERSONVILLE TN
37075-2379
US

V. Phone/Fax

Practice location:
  • Phone: 615-824-0043
  • Fax: 615-822-1690
Mailing address:
  • Phone: 615-824-0043
  • Fax: 615-822-1690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberDO 2430
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberDO 2430
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: