Basic Information
| Provider Information | |||||||||
| NPI: | 1811108061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EL-AMIN | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | C. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5605 GLENRIDGE DR STE 325 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785537783 | ||||||||
| FaxNumber: | 6785537794 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 JOHNSON FERRY RD NE | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048518000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2007 | ||||||||
| LastUpdateDate: | 05/03/2019 | ||||||||
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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 | 2085R0202X | 06072 | GA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.