Provider Demographics
NPI:1881730455
Name:KENNESAW FAMILY PHYSICIANS PC
Entity type:Organization
Organization Name:KENNESAW FAMILY PHYSICIANS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-422-1400
Mailing Address - Street 1:4791 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-5324
Mailing Address - Country:US
Mailing Address - Phone:770-422-1400
Mailing Address - Fax:678-290-6728
Practice Address - Street 1:4791 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-5324
Practice Address - Country:US
Practice Address - Phone:770-422-1400
Practice Address - Fax:678-290-6728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA581584420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA085000643GMedicaid
GAGRP810Medicare ID - Type UnspecifiedMEDICARE