Healthcare Provider Details

I. General information

NPI: 1144462151
Provider Name (Legal Business Name): KENNESTONE HEART PHYSICIANS GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 FOX CHASE
CARTERSVILLE GA
30120-2491
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 770-382-0185
  • Fax: 770-382-0247
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 Number00058204
License Number StateGA

VIII. Authorized Official

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