Provider Demographics
NPI:1619266814
Name:KEN HOMOLYA MD LLC
Entity Type:Organization
Organization Name:KEN HOMOLYA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HOMOLYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-431-5484
Mailing Address - Street 1:625 JOHNNY CASH BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2602
Mailing Address - Country:US
Mailing Address - Phone:615-431-5484
Mailing Address - Fax:615-447-5959
Practice Address - Street 1:625 JOHNNY CASH BLVD STE 3
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2602
Practice Address - Country:US
Practice Address - Phone:615-431-5484
Practice Address - Fax:615-447-5959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-29
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45952208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid
TNPENDINGMedicaid