1386943009 NPI number — KENNESTONE HOSPITAL, INC

Table of content: (NPI 1386943009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386943009 NPI number — KENNESTONE HOSPITAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNESTONE HOSPITAL, INC
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:
WELLSTAR PHARMACY NETWORK
Provider Other Organization Name Type Code:
3
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:
1386943009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 741705
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-1705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3950 AUSTELL RD
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
AUSTELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30106-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-732-2111
Provider Business Practice Location Address Fax Number:
678-495-8798
Provider Enumeration Date:
03/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ERZUAH
Authorized Official First Name:
EBENEZER
Authorized Official Middle Name:
Authorized Official Title or Position:
EXEC DIRECTOR REIMBURSEMENT
Authorized Official Telephone Number:
470-956-4981

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2129620 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 003112057A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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