Basic Information
Provider Information | |||||||||
NPI: | 1992732689 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STISH FAMILY PRACTICE PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1388 | ||||||||
Address2: |   | ||||||||
City: | KINGSTON | ||||||||
State: | PA | ||||||||
PostalCode: | 187040388 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5702888881 | ||||||||
FaxNumber: | 5702888065 | ||||||||
Practice Location | |||||||||
Address1: | 600 PENN ST | ||||||||
Address2: |   | ||||||||
City: | WEST HAZLETON | ||||||||
State: | PA | ||||||||
PostalCode: | 182021514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5704974940 | ||||||||
FaxNumber: | 5704974942 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2006 | ||||||||
LastUpdateDate: | 03/28/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STISH | ||||||||
AuthorizedOfficialFirstName: | EUGENE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5707881108 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 514293 | 01 | PA | PA BLUE SHIELD | OTHER | 002708 | 01 |   | FIRST PRIORITY HEALTH | OTHER |