Basic Information
Provider Information | |||||||||
NPI: | 1548496433 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KENNESTONE HEART PHYSICIANS GROUP, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 1230 JOHNSON FERRY PL | ||||||||
Address2: | SUITE B-10 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300682048 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7705090017 | ||||||||
FaxNumber: | 7709717818 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2009 | ||||||||
LastUpdateDate: | 06/05/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
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ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DOYLE | ||||||||
AuthorizedOfficialFirstName: | KATIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER, PHYSICIAN SERVICES | ||||||||
AuthorizedOfficialTelephone: | 6787974113 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 00058204 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.