Provider Demographics
NPI: | 1659570455 |
---|---|
Name: | LIE, KEVIN T (MD) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | KEVIN |
Middle Name: | T |
Last Name: | LIE |
Suffix: | |
Gender: | M |
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: | PO BOX 1524 |
Mailing Address - Street 2: | |
Mailing Address - City: | AUGUSTA |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30903-1524 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 706-774-7022 |
Mailing Address - Fax: | 706-774-7023 |
Practice Address - Street 1: | 1348 WALTON WAY STE 5700 |
Practice Address - Street 2: | |
Practice Address - City: | AUGUSTA |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30901-5110 |
Practice Address - Country: | US |
Practice Address - Phone: | 706-774-7022 |
Practice Address - Fax: | 706-774-7023 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-07-12 |
Last Update Date: | 2023-04-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 35090995 | 207UN0902X, 207UN0901X, 207UN0903X, 2085B0100X, 2085D0003X, 2085H0002X, 2085N0700X, 2085N0904X, 2085P0229X, 2085R0001X, 2085R0202X, 2085R0203X, 2085R0204X, 207UN0902X |
GA | 81456 | 2085R0204X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0204X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No | 207UN0902X | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy |
No | 207UN0901X | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology |
No | 207UN0903X | Allopathic & Osteopathic Physicians | Nuclear Medicine | In Vivo & In Vitro Nuclear Medicine |
No | 2085B0100X | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
No | 2085D0003X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging |
No | 2085H0002X | Allopathic & Osteopathic Physicians | Radiology | Hospice and Palliative Medicine |
No | 2085N0700X | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
No | 2085N0904X | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology |
No | 2085P0229X | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
No | 2085R0001X | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No | 2085R0203X | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 1025726440001 | Medicaid | |
OH | 465114 | Other | WELLCARE |
OH | 204881619259 | Other | CARESOURCE |
OH | P00648554 | Other | RAILROAD MEDICARE |
OH | 2788381 | Medicaid | |
OH | LI4235041 | Medicare PIN |