Provider Demographics
NPI:1184864258
Name:KENNESTONE HEART PHYSICIANS GROUP, PC
Entity Type:Organization
Organization Name:KENNESTONE HEART PHYSICIANS GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOYLE
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:678-797-4113
Mailing Address - Street 1:355 TOWER RD NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9408
Mailing Address - Country:US
Mailing Address - Phone:770-426-4721
Mailing Address - Fax:770-424-0391
Practice Address - Street 1:720 TRANSIT AVE
Practice Address - Street 2:BUILDING 100, SUITE 102
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2540
Practice Address - Country:US
Practice Address - Phone:770-426-4721
Practice Address - Fax:770-424-0391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-02
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2009PROFS-0051207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300025641KMedicaid