Basic Information
| Provider Information | |||||||||
| NPI: | 1841200375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEYMORE | ||||||||
| FirstName: | KISA | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E 2ND AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1025 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CEDARTOWN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301252036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707480076 | ||||||||
| FaxNumber: | 7707489323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 04/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4221 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207N00000X | 4221 | GA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 003125281A | 05 | GA | MEDICAID |