Provider Demographics
NPI:1548299720
Name:GOSSETT, KENNETH THOMAS (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:THOMAS
Last Name:GOSSETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 TRENT DR SE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-8024
Mailing Address - Country:US
Mailing Address - Phone:706-295-7464
Mailing Address - Fax:
Practice Address - Street 1:100 GROSS CRESCENT CIR
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3643
Practice Address - Country:US
Practice Address - Phone:706-858-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA41127207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA93BFBXCMedicare ID - Type Unspecified
ALG27082Medicare UPIN
GAG27082Medicare UPIN