Provider Demographics
NPI:1841200375
Name:SEYMORE, KISA W (MD)
Entity Type:Individual
Prefix:
First Name:KISA
Middle Name:W
Last Name:SEYMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:420 E 2ND AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3209
Mailing Address - Country:US
Mailing Address - Phone:706-509-3000
Mailing Address - Fax:
Practice Address - Street 1:1025 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2036
Practice Address - Country:US
Practice Address - Phone:770-748-0076
Practice Address - Fax:770-748-9323
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4221207Q00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003125281AMedicaid
GA202I088711Medicare PIN