Provider Demographics
NPI:1700889730
Name:WEISS, KENNETH S (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:WEISS
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 1:6077 PRIMACY PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5742
Mailing Address - Country:US
Mailing Address - Phone:901-641-3000
Mailing Address - Fax:901-701-2400
Practice Address - Street 1:6286 BRIARCREST AVE STE 200
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-4023
Practice Address - Country:US
Practice Address - Phone:901-641-3000
Practice Address - Fax:901-701-2400
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34880207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000125415Medicaid
TN3371161Medicaid
TN3881110OtherCIGNA
MS620819926OtherBCBS
MS7187860Medicaid
TN4014940OtherBCBS
TN620819926OtherAETNA
TN620819926OtherCIGNA
TN620819926OtherTRICARE
AR110318002Medicaid
TN7146128OtherAETNA
AR158715001Medicaid
TN200041126OtherRAILROAD MEDICARE
UT40106OtherTLC
TN3863989Medicaid
TN0723280001Medicare NSC
UT40106OtherTLC
MS7187860Medicaid