Basic Information
| Provider Information | |||||||||
| NPI: | 1255304697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENDERGRAST | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | ROY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HEALTH PARK DR FL HP2 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
| FaxNumber: | 8777672310 | ||||||||
| Practice Location | |||||||||
| Address1: | 2155 APPERSON DR | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241537235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404442010 | ||||||||
| FaxNumber: | 5404442019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101042805 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 04-45914 | KS | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 0101042805 | VA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 04-45914 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6036732 | 05 | VA | MEDICAID | 1255304697 | 05 | VA | MEDICAID |