Provider Demographics
NPI:1902811664
Name:RUTHERFORD, KEVIENE (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIENE
Middle Name:
Last Name:RUTHERFORD
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 1:12755 CENTURY DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-8377
Mailing Address - Country:US
Mailing Address - Phone:770-696-2265
Mailing Address - Fax:
Practice Address - Street 1:12755 CENTURY DR UNIT A
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-8377
Practice Address - Country:US
Practice Address - Phone:770-696-2265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA83610207R00000X, 207R00000X
TN62079207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ061991Medicaid
FL268693700Medicaid
FL277486OtherAMERIGROUP
FL295198OtherAVMED
FL82096OtherBCBS
FL49720OtherNHP
FL9314545OtherPHCS
FL268693700Medicaid
FLP00364557OtherRAILROAD MEDICARE
FL10656OtherDIMENSION
FL12143760OtherMULTIPLAN
FL290496OtherSTAYWELL HEALTH PLAN
FL290496OtherWELLCARE
FL290496OtherWELLCARE
FLP00364557OtherRAILROAD MEDICARE