MEDICARE: EDWARD PARK KANG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician	54147	MN
2	2086S0129X	Vascular Surgery Physician	70309	GA
3	208600000X	Surgery Physician	4301086626	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154504082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD PARK KANG M.D.

Provider Business Mailing Address
First Line	:	980 JOHNSON FY RD NE
Second Line	:	STE 1040
City	:	ATLANTA
State	:	GA
Zip	:	30342-1626
Country	:	US
Telephone Number	:	770-292-3496
Fax Number	:	404-300-2317

Provider Business Practice Location Address
First Line	:	460 NORTHSIDE CHEROKEE BLVD STE 100
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30115-8017
Country	:	US
Telephone Number	:	770-292-3490
Fax Number	:	770-721-5615

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2007
Last Update Date	:	04/27/2021

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Directions to “ EDWARD PARK KANG M.D.” Practice Location

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