Provider Demographics
NPI:1124108923
Name:KIZZIAH, MICHAEL K (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:K
Last Name:KIZZIAH
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 369
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0369
Mailing Address - Country:US
Mailing Address - Phone:706-291-2661
Mailing Address - Fax:706-235-4177
Practice Address - Street 1:255 W 5TH ST SW
Practice Address - Street 2:SUITE 150
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2817
Practice Address - Country:US
Practice Address - Phone:706-232-1545
Practice Address - Fax:706-232-3819
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC279442085B0100X
GA0656942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003123794BMedicaid
SC279442Medicaid
SCAA53289641Medicare PIN
SC279442Medicaid