MEDICARE: LIZY THALIATH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	021929	GA

General Provider Information

NPI Number	:	1891743753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIZY THALIATH MD

Provider Business Mailing Address
First Line	:	445 WINN WAY
Second Line	:	P.O. BOX 1648
City	:	DECATUR
State	:	GA
Zip	:	30030-1707
Country	:	US
Telephone Number	:	404-294-3836
Fax Number	:

Provider Business Practice Location Address
First Line	:	3110 CLIFTON SPRINGS RD
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30034-4600
Country	:	US
Telephone Number	:	404-243-9500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	07/22/2013

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