Provider Demographics
NPI:1750460515
Name:KENNETH MATHEWS JR MD PC
Entity Type:Organization
Organization Name:KENNETH MATHEWS JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MILTON
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD MSPH FACPM
Authorized Official - Phone:423-581-3490
Mailing Address - Street 1:812 WEST 4TH NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814
Mailing Address - Country:US
Mailing Address - Phone:423-581-3490
Mailing Address - Fax:423-581-0657
Practice Address - Street 1:812 WEST 4TH NORTH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814
Practice Address - Country:US
Practice Address - Phone:423-581-3490
Practice Address - Fax:423-581-0657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD012570TN207P00000X, 207Q00000X, 207R00000X, 2083P0500X, 2083P0901X, 208D00000X
NCMD9700433NC207P00000X, 207Q00000X, 2083P0500X
NC9700433NC207R00000X, 2083P0901X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
Not Answered2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D32143Medicare UPIN
3182141Medicare ID - Type Unspecified