Provider Demographics
NPI:1699771949
Name:MCKISSICK, ROBERT ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALAN
Last Name:MCKISSICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1201 MICHIGAN AVE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1580
Mailing Address - Country:US
Mailing Address - Phone:574-722-4921
Mailing Address - Fax:574-739-0520
Practice Address - Street 1:1201 MICHIGAN AVE
Practice Address - Street 2:SUITE 270
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1580
Practice Address - Country:US
Practice Address - Phone:574-722-4921
Practice Address - Fax:574-739-0520
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051621A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200247260Medicaid
000000091515OtherANTHEM BLUE CROSS
4388483OtherAETNA INSURANCE
080151650OtherRAILROAD MEDICARE
IN940670C2Medicare PIN
C45543Medicare UPIN