Provider Demographics
NPI:1417139361
Name:BAIN, KATHRYN VIRGINIA (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:VIRGINIA
Last Name:BAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 AMBULANCE DR 202
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:
Practice Address - Street 1:905 DIXIE STREET
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4454
Practice Address - Country:US
Practice Address - Phone:770-812-5831
Practice Address - Fax:770-812-5832
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061037207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine