Provider Demographics
NPI:1386943009
Name:KENNESTONE HOSPITAL, INC
Entity type:Organization
Organization Name:KENNESTONE HOSPITAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXEC DIRECTOR REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:EBENEZER
Authorized Official - Middle Name:
Authorized Official - Last Name:ERZUAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-956-4981
Mailing Address - Street 1:PO BOX 741705
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3950 AUSTELL RD
Practice Address - Street 2:SUITE 8
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1121
Practice Address - Country:US
Practice Address - Phone:470-732-2111
Practice Address - Fax:678-495-8798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-21
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2129620OtherPK
GA003112057AMedicaid