Provider Demographics
NPI:1972562775
Name:GOEWEY, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GOEWEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 GARDEN LAKES BLVD NW
Mailing Address - Street 2:SUITE D
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1100
Mailing Address - Country:US
Mailing Address - Phone:706-232-6600
Mailing Address - Fax:706-232-6677
Practice Address - Street 1:2400 GARDEN LAKES BLVD NW
Practice Address - Street 2:SUITE D
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1100
Practice Address - Country:US
Practice Address - Phone:706-232-6600
Practice Address - Fax:706-232-6677
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0009891744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1022740OtherACM PROVIDER
GA52071299001OtherBLUE CROSS
GA52071299001OtherBLUE CROSS