Healthcare Provider Details

I. General information

NPI: 1508387499
Provider Name (Legal Business Name): LYDIA KAOUTZANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 JOHN MADDOX DR NW
ROME GA
30165-1413
US

IV. Provider business mailing address

PO BOX 12938 C/O CLINIC MANAGEMENT
CALHOUN GA
30703
US

V. Phone/Fax

Practice location:
  • Phone: 706-368-8550
  • Fax: 706-236-7473
Mailing address:
  • Phone: 706-602-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number103234
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number272276
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: