Healthcare Provider Details

I. General information

NPI: 1962566042
Provider Name (Legal Business Name): KENNESTONE HEART PHYSICIANS GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 04/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 STONEBRIDGE PKWY SUITE 440
WOODSTOCK GA
30189-3767
US

IV. Provider business mailing address

355 TOWER RD NE SUITE 300
MARIETTA GA
30060-9408
US

V. Phone/Fax

Practice location:
  • Phone: 770-426-4721
  • Fax:
Mailing address:
  • Phone: 770-426-4721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number21937
License Number StateGA

VIII. Authorized Official

Name: KATIE M DOYLE
Title or Position: MANAGER, PHYSICIAN SERVICES
Credential:
Phone: 678-797-4113