Provider Demographics
NPI:1790979086
Name:KIM BONDURANT MD PC
Entity Type:Organization
Organization Name:KIM BONDURANT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:BONDURANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-386-0090
Mailing Address - Street 1:962 JOE FRANK HARRIS PKWY SE STE 104
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-2154
Mailing Address - Country:US
Mailing Address - Phone:770-386-0090
Mailing Address - Fax:
Practice Address - Street 1:962 JOE FRANK HARRIS PKWY SE STE 104
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2154
Practice Address - Country:US
Practice Address - Phone:770-386-0090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055208207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7074Medicare PIN