1750460515 NPI number — KENNETH MATHEWS JR MD PC

Table of content: (NPI 1750460515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750460515 NPI number — KENNETH MATHEWS JR MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH MATHEWS JR MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1750460515
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
812 WEST 4TH NORTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORRISTOWN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-581-3490
Provider Business Mailing Address Fax Number:
423-581-0657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
812 WEST 4TH NORTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORRISTOWN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-581-3490
Provider Business Practice Location Address Fax Number:
423-581-0657
Provider Enumeration Date:
11/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MATHEWS
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
MILTON
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
423-581-3490

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  MD012570TN , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207P00000X , with the licence number: MD9700433NC , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207Q00000X , with the licence number: MD012570TN , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207Q00000X , with the licence number: MD9700433NC , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207R00000X , with the licence number: MD012570TN , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207R00000X , with the licence number: 9700433NC , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2083P0500X , with the licence number: MD012570TN , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2083P0500X , with the licence number: MD9700433NC , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2083P0901X , with the licence number: MD012570TN , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2083P0901X , with the licence number: 9700433NC , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208D00000X , with the licence number: MD012570TN , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208D00000X , with the licence number: 9700433NC , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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