Healthcare Provider Details

I. General information

NPI: 1154504082
Provider Name (Legal Business Name): EDWARD PARK KANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 NORTHSIDE CHEROKEE BLVD STE 100
CANTON GA
30115-8017
US

IV. Provider business mailing address

980 JOHNSON FY RD NE STE 1040
ATLANTA GA
30342-1626
US

V. Phone/Fax

Practice location:
  • Phone: 770-292-3490
  • Fax: 770-721-5615
Mailing address:
  • Phone: 770-292-3496
  • Fax: 404-300-2317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301086626
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number54147
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number70309
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: