=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518169812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNETH R. W. WARREN, M.D.P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31 PHYSICIANS DR
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38305-2071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-664-0103
-----------------------------------------------------
Fax | 731-664-5666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 PHYSICIANS DR
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38305-2071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-664-0103
-----------------------------------------------------
Fax | 731-664-5666
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KENNETH RUSSELL WARREN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 731-664-0103
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0000011892
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------