Provider Demographics
NPI:1063480002
Name:KISCH, ETHAN H (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:H
Last Name:KISCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:75 LAMBERT LIND HWY
Mailing Address - Street 2:120-100
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1131
Mailing Address - Country:US
Mailing Address - Phone:401-681-4274
Mailing Address - Fax:401-681-4285
Practice Address - Street 1:75 LAMBERT LIND HWY
Practice Address - Street 2:120-100
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1131
Practice Address - Country:US
Practice Address - Phone:401-681-4274
Practice Address - Fax:401-681-4285
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD102082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI269004146Medicare ID - Type Unspecified
RI007059515Medicare UPIN