Provider Demographics
NPI:1841384518
Name:ANNA K. FARISS, MD, LLC
Entity Type:Organization
Organization Name:ANNA K. FARISS, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:K
Authorized Official - Last Name:FARISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-650-7605
Mailing Address - Street 1:150 E PONCE DE LEON
Mailing Address - Street 2:AVENUE 120
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2543
Mailing Address - Country:US
Mailing Address - Phone:504-650-7605
Mailing Address - Fax:
Practice Address - Street 1:150 E PONCE DE LEON
Practice Address - Street 2:AVENUE 120
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2543
Practice Address - Country:US
Practice Address - Phone:504-650-7605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11309R2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1670821Medicaid
5CF89Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER