Provider Demographics
NPI:1235378324
Name:KENNESAW MOUNTAIN MEDICAL GROUP
Entity Type:Organization
Organization Name:KENNESAW MOUNTAIN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATECHAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-422-5880
Mailing Address - Street 1:1600 KENNESAW DUE WEST RD NW
Mailing Address - Street 2:BUILDING 600 SUITE 625
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4301
Mailing Address - Country:US
Mailing Address - Phone:770-422-5880
Mailing Address - Fax:
Practice Address - Street 1:1600 KENNESAW DUE WEST RD NW
Practice Address - Street 2:BUILDING 600 SUITE 625
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4301
Practice Address - Country:US
Practice Address - Phone:770-422-5880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA52992261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care