MEDICARE: GREGG H.D. KESTERSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	17126	TN
2	207RA0401X	Addiction Medicine (Internal Medicine) Physician	17126	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110098564	OTHER	TN	RR MEDICARE PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376585919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGG H.D. KESTERSON MD

Provider Business Mailing Address
First Line	:	7731 CHEROKEE SPRINGS WAY
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37919-9030
Country	:	US
Telephone Number	:	865-470-2468
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 BROYLES DR
Second Line	:	SUITE B
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-2542
Country	:	US
Telephone Number	:	423-722-4000
Fax Number	:	423-722-4004

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	11/19/2016

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