Provider Demographics
NPI:1427045038
Name:ROBERTSON, KENNETH R (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:ROBERTSON
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 1:1129 HALE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-6373
Mailing Address - Country:US
Mailing Address - Phone:901-396-0390
Mailing Address - Fax:901-396-3728
Practice Address - Street 1:1129 HALE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6373
Practice Address - Country:US
Practice Address - Phone:901-396-0390
Practice Address - Fax:901-396-3728
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD23567208000000X
MSMD13478208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ014826Medicaid
F04190Medicare UPIN