Kenette St-Gourdin, MD

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

96398 Issued in GA

Practice address

631 Campbell Hill St NW Ste 200
Marietta, GA 30060-1390

Phone

(770) 727-4130

Fax

(770) 800-1334

NPI assigned

Apr 3, 2020

Last updated

Dec 4, 2024By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Internal Medicine

Education

Other, 2018

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Epitome Primary CareGroup PAC ID 0042747917, 2 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• FHIR API: https://fhir4.healow.com/fhir/r4/CHGFDD/Endpoint/CHGFDD

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Epitome Primary Care

  • Internal Medicine Physician
  • Marietta, GA
  • NPI 1023835782
  Medicare reassignment Care Compare group NPD Authorized official
• The Southeast Permanente Medical Group

  • Internal Medicine Physician
  • Atlanta, GA
  • NPI 1245266956
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1585872000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1733270400000",
    "number": "1619506557",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "631 CAMPBELL HILL ST NW STE 200",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300601390",
            "telephone_number": "314-448-3791",
            "fax_number": "636-996-7658"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "631 CAMPBELL HILL ST NW STE 200",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300601390",
            "telephone_number": "770-727-4130",
            "fax_number": "770-800-1334"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ST-GOURDIN",
        "first_name": "KENETTE",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2020-04-03",
        "last_updated": "2024-12-04",
        "certification_date": "2024-12-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "GA",
            "license": "96398",
            "primary": true
        },
        {
            "code": "208M00000X",
            "taxonomy_group": "",
            "desc": "Hospitalist",
            "state": "MO",
            "license": "2023049186",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https://epicproxy.et0965.epichosted.com/FHIRProxy/api/FHIR/DSTU2/",
            "affiliation": "N",
            "endpointDescription": "BJC",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "660 Mason Ridge Center Dr Ste 300",
            "city": "Saint Louis",
            "state": "MO",
            "country_code": "US",
            "postal_code": "631418512",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Internal Medicine Physician in Marietta, GA
• Providers in Marietta, GA by specialty
• Internal Medicine Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 4, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.