Healthcare Provider Details

I. General information

NPI: 1508936964
Provider Name (Legal Business Name): KENNY R SINERVO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6105 PEACHTREE DUNWOODY RD BLDG. B; SUITE 230
ATLANTA GA
30328
US

IV. Provider business mailing address

6105 PEACHTREE DUNWOODY RD BLDG B; SUITE 230
ATLANTA GA
30328
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 TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number48574
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number48574
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: