Basic Information
| Provider Information | |||||||||
| NPI: | 1124087168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZELISKO | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1070 MAPLE RIDGE WAY | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306423933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033122572 | ||||||||
| FaxNumber: | 8037651732 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 COWLES CLINC WAY | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306425285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064540159 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 21408 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 82717 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | T54884 | 05 | SC | MEDICAID |