Basic Information
| Provider Information | |||||||||
| NPI: | 1518927110 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISEBRAM | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 PEACHTREE ST NE | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303082208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048811099 | ||||||||
| FaxNumber: | 4048741249 | ||||||||
| Practice Location | |||||||||
| Address1: | 980 JOHNSON FERRY RD NE | ||||||||
| Address2: | SUITE 820 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042529307 | ||||||||
| FaxNumber: | 4042525839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 01/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 022195 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | CB5609 | 01 | RRMEDICARE | OTHER |