Provider Demographics
NPI:1538143292
Name:GISS, STEVEN RANDALL (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:RANDALL
Last Name:GISS
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 CANTERWOOD BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-5817
Mailing Address - Country:US
Mailing Address - Phone:253-530-2940
Mailing Address - Fax:253-857-1489
Practice Address - Street 1:11511 CANTERWOOD BLVD STE 140
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-5817
Practice Address - Country:US
Practice Address - Phone:253-530-2940
Practice Address - Fax:253-857-1489
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22272208600000X
WAMD60891541208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288447Medicaid
OR020045017OtherRR MEDICARE PTAN NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN
WA2111643Medicaid
ORCD8723OtherRR MEDICARE GROUP NUMBER
OR930635514OtherGROUP TAX ID
OR1407812365OtherNBMC NPI NUMBER-GROUP
OR1407812365OtherNBMC NPI NUMBER-GROUP
OR0577260001Medicare NSC