Provider Demographics
NPI:1104891472
Name:BOSS, KENNETH L (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:BOSS
Suffix:
Gender:
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:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:GA
Mailing Address - Zip Code:30110-0728
Mailing Address - Country:US
Mailing Address - Phone:770-537-1234
Mailing Address - Fax:
Practice Address - Street 1:820 MAPLE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3626
Practice Address - Country:US
Practice Address - Phone:678-390-7915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1861915647OtherGROUP NPI
GA277491774AMedicaid
GA277491774AMedicaid