Provider Demographics
NPI:1548239148
Name:GENOVA, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GENOVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MEDICAL DR
Mailing Address - Street 2:SUITE 705
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4155
Mailing Address - Country:US
Mailing Address - Phone:706-885-0111
Mailing Address - Fax:706-885-0607
Practice Address - Street 1:300 MEDICAL DR
Practice Address - Street 2:SUITE 705
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4155
Practice Address - Country:US
Practice Address - Phone:706-885-0111
Practice Address - Fax:706-885-0607
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036977174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00542055AMedicaid
GAF28604Medicare UPIN
GA00542055AMedicaid