Provider Demographics
NPI:1720416480
Name:DR. KISSING OB & GYN
Entity Type:Organization
Organization Name:DR. KISSING OB & GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINIK
Authorized Official - Middle Name:
Authorized Official - Last Name:KISSING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-888-3102
Mailing Address - Street 1:1860 DULUTH HWY
Mailing Address - Street 2:103
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5011
Mailing Address - Country:US
Mailing Address - Phone:770-888-3102
Mailing Address - Fax:770-212-2188
Practice Address - Street 1:1860 DULUTH HWY
Practice Address - Street 2:103
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5011
Practice Address - Country:US
Practice Address - Phone:770-888-3102
Practice Address - Fax:770-212-2188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64125174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112332DMedicaid