Healthcare Provider Details

I. General information

NPI: 1124108923
Provider Name (Legal Business Name): MICHAEL K KIZZIAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W 5TH ST SW SUITE 150
ROME GA
30165-2817
US

IV. Provider business mailing address

PO BOX 369
ROME GA
30162-0369
US

V. Phone/Fax

Practice location:
  • Phone: 706-232-1545
  • Fax: 706-232-3819
Mailing address:
  • Phone: 706-291-2661
  • Fax: 706-235-4177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number27944
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number065694
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: