Healthcare Provider Details

I. General information

NPI: 1255364782
Provider Name (Legal Business Name): KENNETH DALE BEATY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 OLD JEFFERSON
CELINA TN
38551-0217
US

IV. Provider business mailing address

PO BOX 217 100 OLD JEFFERSON ST
CELINA TN
38551-0217
US

V. Phone/Fax

Practice location:
  • Phone: 931-243-6725
  • Fax: 931-243-6727
Mailing address:
  • Phone: 931-243-6725
  • Fax: 931-243-6727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34968
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: