Healthcare Provider Details

I. General information

NPI: 1053305888
Provider Name (Legal Business Name): ELIAS GEORGES ISSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 RIVERSTONE VIS SUITE 207
BLUE RIDGE GA
30513-6648
US

IV. Provider business mailing address

4799 BLUE RIDGE DR SUITE 104
BLUE RIDGE GA
30513-3240
US

V. Phone/Fax

Practice location:
  • Phone: 706-964-4210
  • Fax: 706-964-4251
Mailing address:
  • Phone: 706-946-4210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number056720
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number056720
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number056720
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: