Basic Information
| Provider Information | |||||||||
| NPI: | 1174504260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BYSSHE | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | MARCER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 DUTCHMANS LN | ||||||||
| Address2: | BUILDING B | ||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216014302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108224553 | ||||||||
| FaxNumber: | 4107709611 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 DUTCHMANS LN | ||||||||
| Address2: | BUILDING B | ||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216014302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108224553 | ||||||||
| FaxNumber: | 4107709611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | D23066 | MD | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | E4810001 | 01 | MD | CAREFIRST BLUECHOICE | OTHER | 22322 | 01 | MD | MAMSI | OTHER |