Healthcare Provider Details

I. General information

NPI: 1548239148
Provider Name (Legal Business Name): KENNETH GENOVA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MEDICAL DR SUITE 705
LAGRANGE GA
30240-4155
US

IV. Provider business mailing address

300 MEDICAL DR SUITE 705
LAGRANGE GA
30240-4155
US

V. Phone/Fax

Practice location:
  • Phone: 706-885-0111
  • Fax: 706-885-0607
Mailing address:
  • Phone: 706-885-0111
  • Fax: 706-885-0607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036977
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: