Provider Demographics
NPI:1689756751
Name:TULLIS, KENNETH FRANK (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:FRANK
Last Name:TULLIS
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 1:5158 STAGE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-3116
Mailing Address - Country:US
Mailing Address - Phone:901-383-1924
Mailing Address - Fax:901-383-1925
Practice Address - Street 1:5158 STAGE RD STE 120
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-3116
Practice Address - Country:US
Practice Address - Phone:901-383-1924
Practice Address - Fax:901-383-1925
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD78002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB02623Medicare UPIN
TN3156285Medicare ID - Type Unspecified