1366480014 NPI number — DR. KENNETH W PATRIC JR. MD

Table of content: DR. KENNETH W PATRIC JR. MD (NPI 1366480014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366480014 NPI number — DR. KENNETH W PATRIC JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATRIC
Provider First Name:
KENNETH
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366480014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2485 BASKETTE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37421-7615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-240-4829
Provider Business Mailing Address Fax Number:
615-425-4271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 MCBRIEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST RIDGE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37412-3223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-875-0700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  69243 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD0000027485 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 69243 . This is a "GEORGIA MEDICAL LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".