Provider Demographics
NPI:1235110073
Name:SISUN, HENRY (MSPT)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:
Last Name:SISUN
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:HENRY
Other - Middle Name:
Other - Last Name:SISUN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSPT
Mailing Address - Street 1:721 RESERVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4430
Mailing Address - Country:US
Mailing Address - Phone:401-946-4250
Mailing Address - Fax:401-942-3960
Practice Address - Street 1:721 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-4430
Practice Address - Country:US
Practice Address - Phone:401-946-4250
Practice Address - Fax:401-942-3960
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT00646225100000X
MA5669225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
70151140002OtherCIGNA NON-PAR
MA5712442OtherAETNA INDIVIDUAL #
RI1454-35-0001OtherDMERC ID #
RI401280OtherRI BLUECHIP PROV #
19016OtherNEIGHBORHOOD HEALTH PLAN
RIAA46223OtherHPHC RI PROV ID#
MA605716OtherHPHC MA PROV ID#
RI7536OtherRI BCBS PROV #
RIPT00646OtherPT LICENSE # STATE OF RI
RI2015585OtherAETNA PROV ID#
MAPT0182OtherMEDICARE GROUP # OT SERV
MAY65737OtherMA BCBS PROV ID #
MA5669OtherPT LICENSE STATE OF MA
RI7536OtherRI BCBS PROV #
RI2015585OtherAETNA PROV ID#
MA1454350001Medicare NSC
RI401280OtherRI BLUECHIP PROV #
RI007002734Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER #
MA605716OtherHPHC MA PROV ID#
MAPT0067Medicare ID - Type UnspecifiedMEDICARE GROUP #