=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831162122
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYRIAKOS M. MICHAELIDES MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2006
-----------------------------------------------------
Last Update Date | 07/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 HOSPITAL SOUTH DR SUITE 502
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106-6810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-739-9555
-----------------------------------------------------
Fax | 770-732-8110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 HOSPITAL SOUTH DR SUITE 502
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-741-2317
-----------------------------------------------------
Fax | 678-741-2301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 016644
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 016644
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------