Healthcare Provider Details

I. General information

NPI: 1013385467
Provider Name (Legal Business Name): KENNY R SINERVO MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 HAMMOND DR BLDG F S-6220
ATLANTA GA
30328-5338
US

IV. Provider business mailing address

1140 HAMMOND DR BLDG F S-6220
ATLANTA GA
30328-5338
US

V. Phone/Fax

Practice location:
  • Phone: 770-913-0001
  • Fax: 770-913-0005
Mailing address:
  • Phone: 770-913-0001
  • Fax: 770-913-0005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number1526905
License Number StateGA

VIII. Authorized Official

Name: DR. KENNY R SINERVO
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 770-913-0001