Provider Demographics
NPI:1659565562
Name:KENNESAW PEDIATRICS
Entity Type:Organization
Organization Name:KENNESAW PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-429-1005
Mailing Address - Street 1:3745 CHEROKEE ST NW
Mailing Address - Street 2:SUITE 401
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-6733
Mailing Address - Country:US
Mailing Address - Phone:770-429-1005
Mailing Address - Fax:770-429-8005
Practice Address - Street 1:3745 CHEROKEE ST NW
Practice Address - Street 2:SUITE 401
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-6733
Practice Address - Country:US
Practice Address - Phone:770-429-1005
Practice Address - Fax:770-429-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0048265261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care