1811983299 NPI number — DR. GEORGE T SISSON OD

Table of content: DR. GEORGE T SISSON OD (NPI 1811983299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811983299 NPI number — DR. GEORGE T SISSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SISSON
Provider First Name:
GEORGE
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1811983299
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1070 BASIN ST SW
Provider Second Line Business Mailing Address:
STE F
Provider Business Mailing Address City Name:
EPHRATA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98823-1005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-754-6131
Provider Business Mailing Address Fax Number:
509-754-9243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1070 BASIN ST SW
Provider Second Line Business Practice Location Address:
STE F
Provider Business Practice Location Address City Name:
EPHRATA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98823-1005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-754-6131
Provider Business Practice Location Address Fax Number:
509-754-9243
Provider Enumeration Date:
09/21/2005

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: 152W00000X , with the licence number:  1908 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0681290001 . This is a "MEDICARE DME" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2030252 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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