Basic Information
| Provider Information | |||||||||
| NPI: | 1356506166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KISSWANY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2255260194 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1125 W HIGHWAY 30 | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707375004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256212975 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 11/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 25MB08436700 | NJ | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 000246 | LA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 0172146 | 05 | NJ | MEDICAID | P00829442 | 01 | NJ | RR MEDICARE-TEANECK | OTHER | P00667653 | 01 | NJ | RAILROAD MEDICARE | OTHER | 48090-NON PAR | 01 | NJ | UHP-PHYS ASSOC OF TEANECK | OTHER |