Basic Information
| Provider Information | |||||||||
| NPI: | 1437195377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANBUECKEN | ||||||||
| FirstName: | KENT | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5127 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376025127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239522122 | ||||||||
| FaxNumber: | 4239522145 | ||||||||
| Practice Location | |||||||||
| Address1: | 96 15TH ST NW | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | NORTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242731620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2764391463 | ||||||||
| FaxNumber: | 2764391464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 05/06/2015 | ||||||||
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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 | 207X00000X | MD00026111 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | MD0002611 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 0101255623 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | BV2001737 | 01 | DEA | OTHER | 1437195377 | 05 | VA | MEDICAID | 4586750 | 01 | AETNA | OTHER | Q004984 | 05 | TN | MEDICAID | P01415097 | 01 | VA | RR MEDICARE | OTHER |