Provider Demographics
NPI:1962514927
Name:PHILLIP KISSEL MD, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:PHILLIP KISSEL MD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:KISSEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-544-4455
Mailing Address - Street 1:699 CALIFORNIA BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:699 CALIFORNIA BLVD STE A
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2507
Practice Address - Country:US
Practice Address - Phone:805-544-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53048207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G530480Medicaid
CAG53048OtherSTATE LISCENSE
CAG53048Medicare ID - Type UnspecifiedMEDICARE
CAE75737Medicare UPIN