Provider Demographics
NPI:1487666228
Name:KUTMAH, KHEDER (MD)
Entity Type:Individual
Prefix:
First Name:KHEDER
Middle Name:
Last Name:KUTMAH
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:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41022-0304
Mailing Address - Country:US
Mailing Address - Phone:859-992-4660
Mailing Address - Fax:
Practice Address - Street 1:8820 BANKERS ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4212
Practice Address - Country:US
Practice Address - Phone:859-992-4660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35543207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64030786Medicaid
INM400048469Medicare PIN
KY64030786Medicaid
KY9627Medicare PIN
KY0962701Medicare ID - Type Unspecified
KY1875501Medicare ID - Type Unspecified