Basic Information
| Provider Information | |||||||||
| NPI: | 1043354483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KISSELL | ||||||||
| FirstName: | KERRI | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GUTHRIE SQ | ||||||||
| Address2: | |||||||||
| City: | SAYRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188401625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708885858 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEMORIAL SQ STE 2200 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461401378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174626662 | ||||||||
| FaxNumber: | 3174686275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD430427 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | MD430427 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 039812 | 01 | PA | MEDICARE GROUP | OTHER | CC9269 | 01 | PA | RR MEDICARE GROUP | OTHER | 02889256 | 05 | NY | MEDICAID | GU039812 | 01 | PA | MEDICARE GROUP | OTHER | 1019360730001 | 05 | PA | MEDICAID | P00424192 | 01 | PA | RR MEDICARE PIN | OTHER |