Provider Demographics
NPI:1750625364
Name:KENNETH E. DINELLA MD LLC
Entity type:Organization
Organization Name:KENNETH E. DINELLA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DINELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-928-8868
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-0686
Mailing Address - Country:US
Mailing Address - Phone:229-928-8868
Mailing Address - Fax:229-928-8919
Practice Address - Street 1:1120 ELM AVE
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-4253
Practice Address - Country:US
Practice Address - Phone:229-928-8868
Practice Address - Fax:229-928-8919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0367162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00553253AMedicaid
GA26BDCVBOtherMEDICARE PTAN
GA26BDCVBOtherMEDICARE PTAN