MEDICARE: KENNETH BROOKE BINGHAM PA

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	363A00000X	Physician Assistant	9270	GA

General Provider Information

NPI Number	:	1770131104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH BROOKE BINGHAM PA

Provider Business Mailing Address
First Line	:	1336 HIGHWAY 54 W BLDG 500
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-4574
Country	:	US
Telephone Number	:	770-461-1238
Fax Number	:	770-460-6610

Provider Business Practice Location Address
First Line	:	100 THREE RIVERS DR NE STE A
Second Line	:
City	:	ROME
State	:	GA
Zip	:	30161-4999
Country	:	US
Telephone Number	:	709-292-0040
Fax Number	:	706-378-0556

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

Provider Enumeration Date	:	08/28/2019
Last Update Date	:	04/08/2026

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