Provider Demographics
NPI:1518169812
Name:KENNETH R. W. WARREN, M.D.P.C.
Entity Type:Organization
Organization Name:KENNETH R. W. WARREN, M.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-664-0103
Mailing Address - Street 1:31 PHYSICIANS DR
Mailing Address - Street 2:
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:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000011892207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3168937Medicaid
TN3168937Medicaid
TN3841181Medicare ID - Type Unspecified