Provider Demographics
NPI:1598865396
Name:WILLIAM REYNOLDS SISSON
Entity Type:Organization
Organization Name:WILLIAM REYNOLDS SISSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIDDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-567-3103
Mailing Address - Street 1:7 CRAMER DR
Mailing Address - Street 2:PO BOX 70
Mailing Address - City:NEWPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17074-8720
Mailing Address - Country:US
Mailing Address - Phone:717-567-3103
Mailing Address - Fax:717-567-7784
Practice Address - Street 1:7 CRAMER DR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:PA
Practice Address - Zip Code:17074-8720
Practice Address - Country:US
Practice Address - Phone:717-567-3103
Practice Address - Fax:717-567-7784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000258152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0655810001Medicare NSC
PADD9346Medicare PIN
PA095571Medicare PIN