Provider Demographics
NPI:1417008467
Name:KINNEY, KILE WOODROW (DPM)
Entity Type:Individual
Prefix:DR
First Name:KILE
Middle Name:WOODROW
Last Name:KINNEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 LANEY WALKER BLVD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5827
Mailing Address - Country:US
Mailing Address - Phone:706-724-0586
Mailing Address - Fax:706-724-4468
Practice Address - Street 1:1515 LANEY WALKER BLVD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-5827
Practice Address - Country:US
Practice Address - Phone:706-724-0586
Practice Address - Fax:706-724-4468
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA447213EP1101X, 213ER0200X, 213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA447OtherSTATE LICENSE NUMBER
616548OtherBLUECROSS/BLUESHIELD
GA000167978BMedicaid
GA48SCBTKMedicare PIN
616548OtherBLUECROSS/BLUESHIELD
GA000167978BMedicaid
1196250004Medicare NSC