Healthcare Provider Details

I. General information

NPI: 1538691191
Provider Name (Legal Business Name): KENNETH DISBROW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 JESSE HILL JR DR SE
ATLANTA GA
30303-3049
US

IV. Provider business mailing address

1540 GREGORY AVE
UNION NJ
07083-5542
US

V. Phone/Fax

Practice location:
  • Phone: 404-251-8865
  • Fax: 404-688-6355
Mailing address:
  • Phone: 908-612-0587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number81606
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: