1932342763 NPI number — KENNESTONE HEART PHYSICIANS GROUP, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932342763 NPI number — KENNESTONE HEART PHYSICIANS GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNESTONE HEART PHYSICIANS GROUP, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932342763
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
355 TOWER RD NE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30060-9408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-426-4721
Provider Business Mailing Address Fax Number:
770-424-0391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5671 PEACHTREE DUNWOODY RD NE
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-426-4721
Provider Business Practice Location Address Fax Number:
770-424-0391
Provider Enumeration Date:
04/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DOYLE
Authorized Official First Name:
KATIE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER, PHYSICIAN SERVICES
Authorized Official Telephone Number:
678-797-4113

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  09-00003012 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300025641K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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