Provider Demographics
NPI:1124039334
Name:SHISSIAS, CHARLES G (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:SHISSIAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MIDTOWN DR
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29906-5200
Mailing Address - Country:US
Mailing Address - Phone:843-770-0404
Mailing Address - Fax:803-522-3515
Practice Address - Street 1:300 MIDTOWN DR
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29906-5200
Practice Address - Country:US
Practice Address - Phone:843-770-0404
Practice Address - Fax:803-522-3515
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC216452084N0400X
LAMD11448R2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC216457Medicaid
SCG24405Medicare UPIN
SCG244053230Medicare ID - Type Unspecified