Healthcare Provider Details

I. General information

NPI: 1730406778
Provider Name (Legal Business Name): LERISSA ANN ANTONIO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2010
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5354 REYNOLDS ST STE 424
SAVANNAH GA
31405-6011
US

IV. Provider business mailing address

1 SOUNDING POINT RETREAT
SAVANNAH GA
31411-2839
US

V. Phone/Fax

Practice location:
  • Phone: 912-819-8999
  • Fax:
Mailing address:
  • Phone: 912-272-5549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number70521
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number070521
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME133162
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number83925
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: