Basic Information
| Provider Information | |||||||||
| NPI: | 1184807679 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNA S. GIVEN, MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1499 WALTON WAY | ||||||||
| Address2: | STE 1400 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309012602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067246100 | ||||||||
| FaxNumber: | 7067225187 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 15TH ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067212198 | ||||||||
| FaxNumber: | 7067215748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2007 | ||||||||
| LastUpdateDate: | 12/07/2007 | ||||||||
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| AuthorizedOfficialLastName: | GIVEN | ||||||||
| AuthorizedOfficialFirstName: | KENNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | FULL TIME MD | ||||||||
| AuthorizedOfficialTelephone: | 7067212198 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | GPA764 | 05 | SC | MEDICAID |