1396725214 NPI number — KENNETH W FOGARTY II MD

Table of content: KENNETH W FOGARTY II MD (NPI 1396725214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396725214 NPI number — KENNETH W FOGARTY II MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOGARTY
Provider First Name:
KENNETH
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1396725214
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 908653
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30501-0926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-539-9600
Provider Business Mailing Address Fax Number:
770-534-1470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2350 LIMESTONE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501-2013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-539-9600
Provider Business Practice Location Address Fax Number:
770-534-1470
Provider Enumeration Date:
01/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  041118 , 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: 000679599C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10053087 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 0400123 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 110225630 . This is a "RR MEDICARE-GRP # CC4177" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 336330 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52542692 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 8583747 . This is a "CIGNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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