Basic Information
| Provider Information | |||||||||
| NPI: | 1184864258 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNESTONE HEART PHYSICIANS GROUP, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 355 TOWER RD NE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300609408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704264721 | ||||||||
| FaxNumber: | 7704240391 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 TRANSIT AVE | ||||||||
| Address2: | BUILDING 100, SUITE 102 | ||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301142540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704264721 | ||||||||
| FaxNumber: | 7704240391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2009 | ||||||||
| LastUpdateDate: | 05/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | DOYLE | ||||||||
| AuthorizedOfficialFirstName: | KATIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER, PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6787974113 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | I | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 2009PROFS-0051 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 300025641K | 05 | GA | MEDICAID |