Provider Demographics
NPI:1033359997
Name:LISA A. WIRTH, MD LLC
Entity Type:Organization
Organization Name:LISA A. WIRTH, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-535-2497
Mailing Address - Street 1:500 SPRING ST SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3773
Mailing Address - Country:US
Mailing Address - Phone:770-535-2497
Mailing Address - Fax:770-535-2498
Practice Address - Street 1:500 SPRING ST SE
Practice Address - Street 2:SUITE 201
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3773
Practice Address - Country:US
Practice Address - Phone:770-535-2497
Practice Address - Fax:770-535-2498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-04
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000677795CMedicaid
GA26BDHTCMedicare UPIN