Healthcare Provider Details

I. General information

NPI: 1366480014
Provider Name (Legal Business Name): KENNETH W PATRIC JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 MCBRIEN RD
EAST RIDGE TN
37412-3223
US

IV. Provider business mailing address

2485 BASKETTE WAY
CHATTANOOGA TN
37421-7615
US

V. Phone/Fax

Practice location:
  • Phone: 423-875-0700
  • Fax:
Mailing address:
  • Phone: 423-240-4829
  • Fax: 615-425-4271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number69243
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD0000027485
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: