Basic Information
| Provider Information | |||||||||
| NPI: | 1639160260 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HISSONG | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26035 | ||||||||
| Address2: | RADIOLOGY ASSOCIATES OF CANTON, INC | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443196035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304930840 | ||||||||
| FaxNumber: | 3304937123 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 6TH ST SW | ||||||||
| Address2: | RADIOLOGY ASSOCIATES OF CANTON, INC - ATTN: CECILIA | ||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447101702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303632842 | ||||||||
| FaxNumber: | 3305805536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 09/23/2008 | ||||||||
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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 | 2085R0202X | 35 030121 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300070249 | 01 | OH | RAILROAD MEDICARE | OTHER | 0302836 | 05 | OH | MEDICAID |