Basic Information
| Provider Information | |||||||||
| NPI: | 1356389597 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUNNEELY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
| FaxNumber: | 6158512018 | ||||||||
| Practice Location | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
| FaxNumber: | 6158512018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 04/28/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5223918-1205 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 42095 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1509262 | 01 | TN | MEDICAID - MTI | OTHER | 4200337 | 01 | TN | BCBS TN | OTHER | 30001281 | 05 | TN | MEDICAID | 4155143 | 01 | TN | BCBS | OTHER | 3000128 | 05 | TN | MEDICAID | P00404606 | 01 | TN | RAILROAD MEDICARE | OTHER | 4291494 | 01 | TN | BCBS - MTI | OTHER | 4155167 | 01 | TN | BCBS | OTHER | 7100021580 | 05 | KY | MEDICAID | 1509262 | 05 | TN | MEDICAID |