1962688150 NPI number — MEGAN M SISSON P.T.

Table of content: MEGAN M SISSON P.T. (NPI 1962688150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962688150 NPI number — MEGAN M SISSON P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SISSON
Provider First Name:
MEGAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

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:
1962688150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2223
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 OKATIE VILLAGE DR
Provider Second Line Business Practice Location Address:
STES 105-106
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29909-7528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-706-2861
Provider Business Practice Location Address Fax Number:
843-706-2864
Provider Enumeration Date:
01/17/2008

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: 225100000X , with the licence number:  4603-024 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 8032 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7738 . This is a "DEAN HEALTH INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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