Basic Information
| Provider Information | |||||||||
| NPI: | 1538691191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DISBROW | ||||||||
| FirstName: | KENNETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1540 GREGORY AVE | ||||||||
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| City: | UNION | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070835542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9086120587 | ||||||||
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| Practice Location | |||||||||
| Address1: | 49 JESSE HILL JR DR SE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303033049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042518865 | ||||||||
| FaxNumber: | 4046886355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2017 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 81606 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.