Provider Demographics
NPI:1154167666
Name:KSP HEALTH - TN LLC
Entity type:Organization
Organization Name:KSP HEALTH - TN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MUTHUKUMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:VELLAICHAMY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-516-2853
Mailing Address - Street 1:6446 E CENTRAL AVE STE 183
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-1923
Mailing Address - Country:US
Mailing Address - Phone:316-516-2853
Mailing Address - Fax:
Practice Address - Street 1:116 AGNES RD STE 200
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-6306
Practice Address - Country:US
Practice Address - Phone:316-516-2853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KSP HEALTH - TN LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty