Provider Demographics
NPI:1043221856
Name:WARREN, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:WARREN
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 1:31 PHYSICIANS DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2071
Mailing Address - Country:US
Mailing Address - Phone:731-664-0103
Mailing Address - Fax:731-664-5666
Practice Address - Street 1:31 PHYSICIANS DR
Practice Address - Street 2:SUITE 1
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2071
Practice Address - Country:US
Practice Address - Phone:731-664-0103
Practice Address - Fax:731-664-5666
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000011892207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508946Medicaid
TN4201533OtherBLUE CROSS BLUE SHIELD
TN4201533OtherBLUE CROSS BLUE SHIELD
TN1508946Medicaid