Provider Demographics
NPI:1366480014
Name:PATRIC, KENNETH W JR (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:PATRIC
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2485 BASKETTE WAY
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-7615
Mailing Address - Country:US
Mailing Address - Phone:423-240-4829
Mailing Address - Fax:615-425-4271
Practice Address - Street 1:403 MCBRIEN RD
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412-3223
Practice Address - Country:US
Practice Address - Phone:423-875-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA69243207Q00000X
TNMD0000027485207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA69243OtherGEORGIA MEDICAL LICENSE
A46207Medicare UPIN