Healthcare Provider Details

I. General information

NPI: 1770131104
Provider Name (Legal Business Name): KENNETH BROOKE BINGHAM PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1336 HIGHWAY 54 W BLDG 500
FAYETTEVILLE GA
30214-4574
US

IV. Provider business mailing address

1336 HIGHWAY 54 W BLDG 500
FAYETTEVILLE GA
30214-4574
US

V. Phone/Fax

Practice location:
  • Phone: 770-461-1238
  • Fax: 770-460-6610
Mailing address:
  • Phone: 770-461-1238
  • Fax: 770-460-6610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9270
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: