Basic Information
| Provider Information | |||||||||
| NPI: | 1891747853 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JUSTICE | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 440061 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372440061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656706199 | ||||||||
| FaxNumber: | 8656706198 | ||||||||
| Practice Location | |||||||||
| Address1: | 435 PARKWAY | ||||||||
| Address2: | |||||||||
| City: | SEVIERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378624152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659080400 | ||||||||
| FaxNumber: | 8654537009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 04/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 30763 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3831219 | 05 | TN | MEDICAID | 3831218 | 05 | TN | MEDICAID |