Provider Demographics
NPI:1255364782
Name:BEATY, KENNETH DALE (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DALE
Last Name:BEATY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:100 OLD JEFFERSON ST
Mailing Address - City:CELINA
Mailing Address - State:TN
Mailing Address - Zip Code:38551-0217
Mailing Address - Country:US
Mailing Address - Phone:931-243-6725
Mailing Address - Fax:931-243-6727
Practice Address - Street 1:100 OLD JEFFERSON
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:TN
Practice Address - Zip Code:38551-0217
Practice Address - Country:US
Practice Address - Phone:931-243-6725
Practice Address - Fax:931-243-6727
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3861533Medicaid
TN3861533Medicare ID - Type UnspecifiedMEDICARE
TNH32108Medicare UPIN