Provider Demographics
NPI:1306863741
Name:TISOVEC, RICHARD WARREN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WARREN
Last Name:TISOVEC
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:PO BOX 14944
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415-4944
Mailing Address - Country:US
Mailing Address - Phone:336-621-8911
Mailing Address - Fax:336-621-6322
Practice Address - Street 1:2703 HENRY ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3669
Practice Address - Country:US
Practice Address - Phone:336-621-8911
Practice Address - Fax:336-621-6322
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891305RMedicaid
NC891305RMedicaid
H57899Medicare UPIN