Provider Demographics
NPI:1790812451
Name:JOHN LEX KENERLY, III, MD
Entity Type:Organization
Organization Name:JOHN LEX KENERLY, III, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LEX
Authorized Official - Last Name:KENERLY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:912-427-0800
Mailing Address - Street 1:PO BOX 1334
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31598-1334
Mailing Address - Country:US
Mailing Address - Phone:912-427-0800
Mailing Address - Fax:912-427-6029
Practice Address - Street 1:811 S 1ST ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0209
Practice Address - Country:US
Practice Address - Phone:912-427-0800
Practice Address - Fax:912-427-6029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030633207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000374921AMedicaid
GA000374921AMedicaid
GAGRP2412Medicare PIN
GA200004881Medicare PIN