1922197045 NPI number — DR. CHAD M SISK D.O.

Table of content: DR. CHAD M SISK D.O. (NPI 1922197045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922197045 NPI number — DR. CHAD M SISK D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SISK
Provider First Name:
CHAD
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922197045
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 LOWER FAYETTEVILLE RD STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWNAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30265-1133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-631-4610
Provider Business Mailing Address Fax Number:
678-388-1759

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1551 DOCTORS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30240-4139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-845-7711
Provider Business Practice Location Address Fax Number:
706-882-1620
Provider Enumeration Date:
10/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  DO-558 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 059201 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)