Healthcare Provider Details

I. General information

NPI: 1083171607
Provider Name (Legal Business Name): COLUMBUS MEMORY CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7196 N LAKE DR
COLUMBUS GA
31909-1693
US

IV. Provider business mailing address

7196 N LAKE DR
COLUMBUS GA
31909-1693
US

V. Phone/Fax

Practice location:
  • Phone: 706-327-4000
  • Fax: 706-324-2557
Mailing address:
  • Phone: 706-327-4000
  • Fax: 706-324-2557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN LEONARD LISS
Title or Position: PRESIDENT
Credential: MD
Phone: 706-327-4000