Basic Information
| Provider Information | |||||||||
| NPI: | 1508250515 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEMAIO | ||||||||
| FirstName: | KRISTINE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 WOODRUFF CIR NE DEPT OF | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4044716375 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018151292 | ||||||||
| FaxNumber: | 6019845110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2015 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 92955 | GA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208600000X | T2942 | MS | N | Allopathic & Osteopathic Physicians | Surgery | 2085R0204X | 92955 | GA | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 03830326 | 05 | MS | MEDICAID |