Healthcare Provider Details

I. General information

NPI: 1700047784
Provider Name (Legal Business Name): KEREN AVIVA BASHAN-GILZENRAT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2008
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE STE 130
MARIETTA GA
30060
US

IV. Provider business mailing address

805 SANDY PLAINS ROAD MEDICAL STAFF SERVICES
MARIETTA GA
30066-6340
US

V. Phone/Fax

Practice location:
  • Phone: 770-426-1629
  • Fax: 770-427-8001
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2014-01249
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number070045
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: