Provider Demographics
NPI:1790738904
Name:DIVER, KERRY CHESTER (MD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:CHESTER
Last Name:DIVER
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 1:1 FREEDOM WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6258
Mailing Address - Country:US
Mailing Address - Phone:706-733-0188
Mailing Address - Fax:706-729-5748
Practice Address - Street 1:1303 DANTIGNAC ST
Practice Address - Street 2:SUITE #1200
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2775
Practice Address - Country:US
Practice Address - Phone:706-774-7760
Practice Address - Fax:706-774-7766
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23041261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
D29311Medicare UPIN
GA11BDPWSMedicare ID - Type Unspecified