Provider Demographics
NPI:1275584716
Name:O'KELLEY, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:O'KELLEY
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 1:9430 PARKWEST BLVD
Mailing Address - Street 2:SUITE
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923
Mailing Address - Country:US
Mailing Address - Phone:865-769-4444
Mailing Address - Fax:865-769-4395
Practice Address - Street 1:9430 PARKWEST BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923
Practice Address - Country:US
Practice Address - Phone:865-769-4444
Practice Address - Fax:865-769-4395
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD012163207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3034509Medicaid
TN3034509Medicaid
TNA99801Medicare UPIN