Provider Demographics
NPI:1376793737
Name:SISSON, ALAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:L
Last Name:SISSON
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 1:68 FONTAINE CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2537
Mailing Address - Country:US
Mailing Address - Phone:630-283-5646
Mailing Address - Fax:630-283-5646
Practice Address - Street 1:1229 N NORTH BRANCH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2473
Practice Address - Country:US
Practice Address - Phone:213-939-5090
Practice Address - Fax:312-640-4496
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088113207QG0300X, 207RG0300X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA694878Medicaid
IA694878Medicaid