Provider Demographics
NPI:1235283854
Name:KEVIENE RUTHERFORD MD PA
Entity Type:Organization
Organization Name:KEVIENE RUTHERFORD MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIENE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-732-8355
Mailing Address - Street 1:10075 JOG ROAD
Mailing Address - Street 2:SUITE 311
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-3537
Mailing Address - Country:US
Mailing Address - Phone:561-732-8355
Mailing Address - Fax:561-732-8358
Practice Address - Street 1:10075 S JOG RD
Practice Address - Street 2:SUITE 311
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3535
Practice Address - Country:US
Practice Address - Phone:561-732-8355
Practice Address - Fax:561-732-8358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87247207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82096ZMedicare PIN
FLK5546Medicare PIN