Healthcare Provider Details

I. General information

NPI: 1184864258
Provider Name (Legal Business Name): KENNESTONE HEART PHYSICIANS GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2009
Last Update Date: 05/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 TRANSIT AVE BUILDING 100, SUITE 102
CANTON GA
30114-2540
US

IV. Provider business mailing address

355 TOWER RD NE SUITE 300
MARIETTA GA
30060-9408
US

V. Phone/Fax

Practice location:
  • Phone: 770-426-4721
  • Fax: 770-424-0391
Mailing address:
  • Phone: 770-426-4721
  • Fax: 770-424-0391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2009PROFS-0051
License Number StateGA

VIII. Authorized Official

Name: KATIE DOYLE I
Title or Position: MANAGER, PHYSICIAN SERVICES
Credential:
Phone: 678-797-4113