Provider Demographics
NPI:1275759011
Name:KENNETH J PHELPS MD
Entity Type:Organization
Organization Name:KENNETH J PHELPS MD
Other - Org Name:KENNETH PHELPS MD & ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-359-3551
Mailing Address - Street 1:304 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37091-2730
Mailing Address - Country:US
Mailing Address - Phone:931-359-3551
Mailing Address - Fax:931-359-8421
Practice Address - Street 1:304 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-2730
Practice Address - Country:US
Practice Address - Phone:931-359-3551
Practice Address - Fax:931-359-8421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD7988174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3719237Medicare ID - Type Unspecified