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General NPI Number Information
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NPI Number | 1881730455
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Entity Type | Organization
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Legal Business Name | KENNESAW FAMILY PHYSICIANS PC
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Dates
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Enumeration Date | 01/30/2007
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Last Update Date | 10/22/2012
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Provider Practice Location Address
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Address Line | 4791 S MAIN ST
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City | ACWORTH
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State | GA
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Zip | 30101-5324
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Country | US
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Telephone | 770-422-1400
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Fax | 678-290-6728
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Provider Business Mailing Address
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Address Line | 4791 S MAIN ST
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City | ACWORTH
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State | GA
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Zip | 30101-5324
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Country | US
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Telephone | 770-422-1400
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Fax | 678-290-6728
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. CONNIE H. KELLER
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Credential |
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Telephone | 770-422-1400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 581584420
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License Number State | GA
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