Provider Demographics
NPI:1932150729
Name:KINNEBREW, TODD E (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:E
Last Name:KINNEBREW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MARGIE DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-7818
Mailing Address - Country:US
Mailing Address - Phone:478-971-1153
Mailing Address - Fax:478-971-1173
Practice Address - Street 1:301 MARGIE DR
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-7818
Practice Address - Country:US
Practice Address - Phone:478-971-1153
Practice Address - Fax:478-971-1173
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037009207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000539844FMedicaid
GA000539844FMedicaid
GAGRP1302Medicare PIN