Provider Demographics
NPI:1255304697
Name:PENDERGRAST, KENNETH ROY (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROY
Last Name:PENDERGRAST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 HEALTH PARK DR FL HP2
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:877-767-2310
Practice Address - Street 1:2155 APPERSON DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7235
Practice Address - Country:US
Practice Address - Phone:540-444-2010
Practice Address - Fax:540-444-2019
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042805207R00000X, 208M00000X
KS04-45914208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6036732Medicaid
VA1255304697Medicaid
VA6036732Medicaid
VA110003566Medicare ID - Type Unspecified