Provider Demographics
NPI:1093818312
Name:KIRKLAND, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KIRKLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 PEACHTREE ST NE
Mailing Address - Street 2:NORTH TOWER, SUITE 2100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-1401
Mailing Address - Country:US
Mailing Address - Phone:770-994-9326
Mailing Address - Fax:770-994-4747
Practice Address - Street 1:350 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3838
Practice Address - Country:US
Practice Address - Phone:770-994-9326
Practice Address - Fax:770-994-4747
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA46314207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD413046400Medicaid
MD413496600Medicaid
MD489PR831Medicare PIN
MDR831Medicare PIN
MD413496600Medicaid