Provider Demographics
NPI:1225495435
Name:MARY E TISSERAND MD PC
Entity Type:Organization
Organization Name:MARY E TISSERAND MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:TISSERAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-476-1379
Mailing Address - Street 1:3700 BELLEMEADE AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0125
Mailing Address - Country:US
Mailing Address - Phone:812-476-1379
Mailing Address - Fax:
Practice Address - Street 1:3700 BELLEMEADE AVE
Practice Address - Street 2:STE 200
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0125
Practice Address - Country:US
Practice Address - Phone:812-476-1379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037184207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INE03773Medicare UPIN