Provider Demographics
NPI:1538107206
Name:OOTHOUT, KEVIN BRADBURY (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:BRADBURY
Last Name:OOTHOUT
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 634706
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:391 WALLACE RD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-4851
Practice Address - Country:US
Practice Address - Phone:615-781-4605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD024636207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3122698OtherBLUE CROSS
TNP00208403OtherMEDICARE RAILROAD
TN33323OtherTLC TENNCARE
TN4079134OtherBLUE CROSS
TN4079137OtherBLUE CROSS
TNP00222460OtherMEDICARE RAILROAD
TN3746649Medicaid
TN3846640Medicaid
TN3846641Medicaid
TN41242OtherTLC TENNCARE
F51680Medicare UPIN
TN3846640Medicaid
TN3846641Medicaid
TN41242OtherTLC TENNCARE