Basic Information
| Provider Information | |||||||||
| NPI: | 1700872959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUTSHALL | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52948 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379502948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653065700 | ||||||||
| FaxNumber: | 8655847760 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 PROFESSIONAL PARK DR STE 11 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239755650 | ||||||||
| FaxNumber: | 4239755652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD19352 | TN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | Q009403 | 05 | TN | MEDICAID | 3001652350001 | 05 | VA | MEDICAID |