1235110073 NPI number — MR. HENRY SISUN M.S.P.T.

Table of content: MR. HENRY SISUN M.S.P.T. (NPI 1235110073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235110073 NPI number — MR. HENRY SISUN M.S.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SISUN
Provider First Name:
HENRY
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.S.P.T.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SISUN
Provider Other First Name:
HENRY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S.P.T.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1235110073
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
721 RESERVOIR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRANSTON
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02910-4430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-946-4250
Provider Business Mailing Address Fax Number:
401-942-3960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
721 RESERVOIR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRANSTON
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02910-4430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-946-4250
Provider Business Practice Location Address Fax Number:
401-942-3960
Provider Enumeration Date:
11/09/2005

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:  PT00646 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 5669 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 70151140002 . This is a "CIGNA NON-PAR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5712442 . This is a "AETNA INDIVIDUAL #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1454-35-0001 . This is a "DMERC ID #" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 401280 . This is a "RI BLUECHIP PROV #" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 19016 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA46223 . This is a "HPHC RI PROV ID#" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 605716 . This is a "HPHC MA PROV ID#" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 7536 . This is a "RI BCBS PROV #" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: PT00646 . This is a "PT LICENSE # STATE OF RI" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 2015585 . This is a "AETNA PROV ID#" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: PT0182 . This is a "MEDICARE GROUP # OT SERV" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y65737 . This is a "MA BCBS PROV ID #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 5669 . This is a "PT LICENSE STATE OF MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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