Basic Information
| Provider Information | |||||||||
| NPI: | 1366522690 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNOWLTON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5671 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303425000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048557030 | ||||||||
| FaxNumber: | 6788436619 | ||||||||
| Practice Location | |||||||||
| Address1: | 5671 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303425000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048557030 | ||||||||
| FaxNumber: | 6788436619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 01/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 018037 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 00143943A | 05 | GA | MEDICAID |