Provider Demographics
NPI:1972679918
Name:FITZGERALD, KELLEEN C (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLEEN
Middle Name:C
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 JOHNSON FERRY RD.
Mailing Address - Street 2:BLDG. II, SUITE 460
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1709
Mailing Address - Country:US
Mailing Address - Phone:404-256-1104
Mailing Address - Fax:404-256-2060
Practice Address - Street 1:1100 JOHNSON FERRY RD.
Practice Address - Street 2:BLDG. II, SUITE 460
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1709
Practice Address - Country:US
Practice Address - Phone:404-256-1104
Practice Address - Fax:404-256-2060
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA40661207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11BDQXCMedicare ID - Type Unspecified
GAG54484Medicare UPIN