Basic Information
| Provider Information | |||||||||
| NPI: | 1205375623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDEN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | GRAYSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9172 DAYFLOWER DR | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237627083 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7031 SW 62ND AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331434701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055582500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2017 | ||||||||
| LastUpdateDate: | 07/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 04949 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 04949 | KY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.