Provider Demographics
NPI:1659352185
Name:LISA D MILLER MD PEDIATRICS PC
Entity Type:Organization
Organization Name:LISA D MILLER MD PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-788-1077
Mailing Address - Street 1:4152 BAKER ST NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-1404
Mailing Address - Country:US
Mailing Address - Phone:770-788-1077
Mailing Address - Fax:770-788-0768
Practice Address - Street 1:4152 BAKER ST NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1404
Practice Address - Country:US
Practice Address - Phone:770-788-1077
Practice Address - Fax:770-788-0768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013449208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00618945DMedicaid
GA581934OtherBCBS
GA00618945EMedicaid