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General NPI Number Information
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NPI Number | 1093931800
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Entity Type | Organization
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Legal Business Name | KENNESTONE INTERNAL MEDICINE ASSOCIATES PC
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Dates
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Enumeration Date | 04/18/2007
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Last Update Date | 01/16/2013
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Provider Practice Location Address
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Address Line | 790 CHURCH ST NE STE 325
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City | MARIETTA
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State | GA
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Zip | 30060-7282
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Country | US
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Telephone | 770-419-7074
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Fax |
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Provider Business Mailing Address
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Address Line | 790 CHURCH ST NE STE 325
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City | MARIETTA
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State | GA
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Zip | 30060-7282
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Country | US
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Telephone | 770-419-7074
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | RENAE FORRESTER
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Credential |
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Telephone | 770-419-7074
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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