Provider Demographics
NPI:1093931800
Name:KENNESTONE INTERNAL MEDICINE ASSOCIATES PC
Entity Type:Organization
Organization Name:KENNESTONE INTERNAL MEDICINE ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RENAE
Authorized Official - Middle Name:
Authorized Official - Last Name:FORRESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-419-7074
Mailing Address - Street 1:790 CHURCH ST NE
Mailing Address - Street 2:STE 325
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7282
Mailing Address - Country:US
Mailing Address - Phone:770-419-7074
Mailing Address - Fax:
Practice Address - Street 1:790 CHURCH ST NE
Practice Address - Street 2:STE 325
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7282
Practice Address - Country:US
Practice Address - Phone:770-419-7074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty