Provider Demographics
NPI:1508865445
Name:KEN KOZAWA I MD PC
Entity Type:Organization
Organization Name:KEN KOZAWA I MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOZAWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-213-8590
Mailing Address - Street 1:304 WRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TN
Mailing Address - Zip Code:37874-1181
Mailing Address - Country:US
Mailing Address - Phone:865-213-8200
Mailing Address - Fax:865-213-8596
Practice Address - Street 1:304 WRIGHT ST
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TN
Practice Address - Zip Code:37874-1181
Practice Address - Country:US
Practice Address - Phone:865-213-8200
Practice Address - Fax:865-213-8596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25483207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3733125Medicaid
4121508OtherBC
TN3729045Medicare PIN
4121508OtherBC
TN3733125Medicaid