Basic Information
Provider Information | |||||||||
NPI: | 1790756450 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KENT | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | C. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STOREN | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: | C. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 102222 | ||||||||
Address2: | ATTN: CREDENTIALING | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303682222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2394328331 | ||||||||
FaxNumber: | 8139767895 | ||||||||
Practice Location | |||||||||
Address1: | 4689 US HIGHWAY 17 STE 2-5 | ||||||||
Address2: |   | ||||||||
City: | FLEMING ISLAND | ||||||||
State: | FL | ||||||||
PostalCode: | 320034831 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042696526 | ||||||||
FaxNumber: | 9042696527 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2006 | ||||||||
LastUpdateDate: | 08/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | ME116639 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RX0202X | ME116639 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
ID | Type | State | Issuer | Description | 009197200 | 05 | FL |   | MEDICAID |