Basic Information
| Provider Information | |||||||||
| NPI: | 1235174723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADKISSON | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 RANCH RD | ||||||||
| Address2: | |||||||||
| City: | REEDSPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974671720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412712171 | ||||||||
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| Practice Location | |||||||||
| Address1: | 385 RANCH RD | ||||||||
| Address2: | |||||||||
| City: | REEDSPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974671707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412712119 | ||||||||
| FaxNumber: | 5412719338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 11/19/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 22387 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD154233 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 840428757017 | 01 | CO | ROCKY MOUNTAIN HEALTH PLA | OTHER | 500639477 | 05 | OR | MEDICAID | 01223874 | 05 | CO | MEDICAID | AD376766 | 01 | CO | BCBS | OTHER |