Provider Demographics
NPI:1992868855
Name:PERISSEIA PHYSICIANS, LLC
Entity type:Organization
Organization Name:PERISSEIA PHYSICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:KUNZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-682-2024
Mailing Address - Street 1:1655 LEBANON RD
Mailing Address - Street 2:STE A
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5128
Mailing Address - Country:US
Mailing Address - Phone:770-682-2024
Mailing Address - Fax:770-682-2034
Practice Address - Street 1:1655 LEBANON RD
Practice Address - Street 2:STE A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5128
Practice Address - Country:US
Practice Address - Phone:770-682-2024
Practice Address - Fax:770-682-2034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029703173000000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Not Answered261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BBVLJMedicare ID - Type UnspecifiedKUNZ MEDICARE NUMBER
GAD45891Medicare UPIN