Healthcare Provider Details

I. General information

NPI: 1447769641
Provider Name (Legal Business Name): KEN HOMOLYA MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5114 OLD HICKORY BLVD STE 201
HERMITAGE TN
37076-2590
US

IV. Provider business mailing address

103 HAZEL PATH STE 7
HENDERSONVILLE TN
37075-3893
US

V. Phone/Fax

Practice location:
  • Phone: 615-850-6960
  • Fax: 615-777-3393
Mailing address:
  • Phone: 615-431-5484
  • Fax: 615-447-5959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KENNETH M HOMOLYA
Title or Position: OWNER
Credential: MD
Phone: 615-431-5484