Healthcare Provider Details

I. General information

NPI: 1467517391
Provider Name (Legal Business Name): KINNEBREW ORTHOPEDICS & SPORTS MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 06/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MARGIE DR
WARNER ROBINS GA
31088-7818
US

IV. Provider business mailing address

301 MARGIE DR
WARNER ROBINS GA
31088-7818
US

V. Phone/Fax

Practice location:
  • Phone: 478-971-1153
  • Fax: 478-971-1173
Mailing address:
  • Phone: 478-971-1153
  • Fax: 478-971-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number037009
License Number StateGA

VIII. Authorized Official

Name: TODD E. KINNEBREW
Title or Position: OWNER
Credential: M.D.
Phone: 478-971-1153