Provider Demographics
NPI:1568523199
Name:HANISH, SIDNEY J (MD)
Entity Type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:J
Last Name:HANISH
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 1:1A VILLAGE SQUARE SHOP CTR
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1817
Mailing Address - Country:US
Mailing Address - Phone:314-731-5656
Mailing Address - Fax:314-731-3215
Practice Address - Street 1:1A VILLAGE SQUARE SHOP CTR
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1817
Practice Address - Country:US
Practice Address - Phone:314-731-5656
Practice Address - Fax:314-731-3215
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR8613207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
118695OtherHEALTHLINK
IL0006005882OtherBLUE CROSS BLUE SHIELD
IL989200Medicare PIN
IL0006005882OtherBLUE CROSS BLUE SHIELD