=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073563250
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA IRENE GRIGGS M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 902 CLARK ST
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30720-8721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-529-3245
-----------------------------------------------------
Fax | 706-272-6077
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 902 CLARK ST
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30720-8721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-980-7238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 056715
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD447136
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 38669
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------