NPIMap

Organization Active NPI

Kennesaw Family Physicians PC

Doing business as Main Street Family Physicians

  • Family Medicine Physician
  • Acworth, GA
National Provider Identifier
1881730455
Registry record updated Oct 22, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
581584420 Issued in GA
Legal business name
KENNESAW FAMILY PHYSICIANS PC
Doing business as
Main Street Family Physicians
Practice address
4791 S Main St
Acworth, GA 30101-5324
Phone
(770) 422-1400
Fax
(678) 290-6728
NPI assigned
Jan 30, 2007
Last updated
Oct 22, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 22, 2012

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

Authorized official

Name
Mrs. Connie H. Keller
Title
Office Manager
Phone
(770) 422-1400

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 581584420 GA Primary

Addresses

Primary practice location

4791 S Main St
Acworth, GA 30101-5324

Mailing address

4791 S Main St
Acworth, GA 30101-5324
Phone (770) 422-1400

Other identifiers 1

IdentifierTypeStateIssuer
085000643GMedicaidGA

Other names 1

  • Main Street Family Physicians Doing business as

National Provider Directory

National Provider Directory

Locations

4791 S Main St
Acworth, GA 30101
Phone (770) 422-1400

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1170115200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1350864000000",
    "number": "1881730455",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4791 S MAIN ST",
            "city": "ACWORTH",
            "state": "GA",
            "postal_code": "301015324",
            "telephone_number": "770-422-1400",
            "fax_number": "678-290-6728"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4791 S MAIN ST",
            "city": "ACWORTH",
            "state": "GA",
            "postal_code": "301015324",
            "telephone_number": "770-422-1400",
            "fax_number": "678-290-6728"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KENNESAW FAMILY PHYSICIANS PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-30",
        "last_updated": "2012-10-22",
        "status": "A",
        "authorized_official_last_name": "KELLER",
        "authorized_official_first_name": "CONNIE",
        "authorized_official_middle_name": "H.",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "770-422-1400",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "GA",
            "license": "581584420",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "085000643G",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Main Street Family Physicians",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Acworth, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 22, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.