Provider Demographics
NPI:1396921417
Name:KENNETH A. HOOSE, JR., M.D., P.C.
Entity type:Organization
Organization Name:KENNETH A. HOOSE, JR., M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:HOOSE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:404-501-7640
Mailing Address - Street 1:2675 N DECATUR RD
Mailing Address - Street 2:SUITE 607
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6131
Mailing Address - Country:US
Mailing Address - Phone:404-501-7640
Mailing Address - Fax:404-501-7601
Practice Address - Street 1:2675 N DECATUR RD
Practice Address - Street 2:SUITE 607
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6131
Practice Address - Country:US
Practice Address - Phone:404-501-7640
Practice Address - Fax:404-501-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10962207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA011003745OtherMEDICARE RAILROAD
GA048575OtherBLUE CROSS/BLUE SHIELD
GA000098876AMedicaid
GA048575OtherBLUE CROSS/BLUE SHIELD