MEDICARE: DR. JONATHAN LEONARD LISS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	039850	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386613743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN LEONARD LISS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 160
Second Line	:
City	:	FORTSON
State	:	GA
Zip	:	31808-0160
Country	:	US
Telephone Number	:	706-327-4000
Fax Number	:	706-324-2557

Provider Business Practice Location Address
First Line	:	7196 N LAKE DR
Second Line	:	SUITE A
City	:	COLUMBUS
State	:	GA
Zip	:	31909-1693
Country	:	US
Telephone Number	:	706-327-4000
Fax Number	:	706-324-2557

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	07/08/2007

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