Samuel Kissiedu

Primary specialty

Physician AssistantTaxonomy code 363A00000X

Practice address

6102 Jefferson Cir S
Chamblee, GA 30341-2661

Phone

(321) 274-5712

NPI assigned

Sep 20, 2023

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in FL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2024

Medicare assignment

May accept Medicare assignment

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Leesburg Regional Medical Center Physician Services LLC

  • Emergency Medicine Physician
  • Leesburg, FL
  • NPI 1104063114
  Medicare reassignment
• Villages Regional Hospital Physician Services LLC

  • Surgery Physician
  • Leesburg, FL
  • NPI 1700669926
  Medicare reassignment

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1695168000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1695168000000",
    "number": "1235917154",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6102 JEFFERSON CIR S",
            "city": "CHAMBLEE",
            "state": "GA",
            "postal_code": "303412661",
            "telephone_number": "321-274-5712"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6102 JEFFERSON CIR S",
            "city": "CHAMBLEE",
            "state": "GA",
            "postal_code": "303412661",
            "telephone_number": "321-274-5712"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KISSIEDU",
        "first_name": "SAMUEL",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2023-09-20",
        "last_updated": "2023-09-20",
        "certification_date": "2023-09-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Allison Keener, RBT
• Christine J Kennedy, P.D.,PH.D., R.PH.
• Gi Young Kim, NP-C
• Marika King, SLP
• Ania Beth Kirollos
• Jacquelyn Gabrielle Kistenberg, RNFA
• Marlene Peters Knieper, RN
• KPM, LLC
• Kufahl & Peeples Management
• Amber K Lalani, NP

• Physician Assistant in Chamblee, GA
• Providers in Chamblee, GA by specialty
• Physician Assistant in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 20, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.