Healthcare Provider Details

I. General information

NPI: 1023059581
Provider Name (Legal Business Name): BRENDA L MARINO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 CHURCH ST HOSPITAL BASED ONLY KENNESTONE WELLSTAR
MARIETTA GA
30060
US

IV. Provider business mailing address

PO BOX 4214
MARIETTA GA
30061
US

V. Phone/Fax

Practice location:
  • Phone: 770-779-3603
  • Fax: 770-793-9925
Mailing address:
  • Phone: 770-427-4800
  • Fax: 770-427-3653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number016392
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: