1396780516 NPI number — KENNETH C REESE MD

Table of content: KENNETH C REESE MD (NPI 1396780516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396780516 NPI number — KENNETH C REESE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REESE
Provider First Name:
KENNETH
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
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:
1396780516
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1225 E WEISGARBER RD
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37909-2604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-584-4747
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 LAUREL AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37916-1810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-577-9247
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/19/2006

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: 207R00000X , with the licence number:  23978 , 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: 3071267 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3706633 . This is a "MEDICARE GROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 110166468 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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