Provider Demographics
NPI:1619995305
Name:SISSON, BETSY A (MD)
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:A
Last Name:SISSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 GRANITE AVENUE
Mailing Address - Street 2:EAST MILTON PEDIATRIC ASSOC INC
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-5625
Mailing Address - Country:US
Mailing Address - Phone:617-696-5900
Mailing Address - Fax:617-696-0363
Practice Address - Street 1:464 GRANITE AVENUE
Practice Address - Street 2:EAST MILTON PEDIATRIC ASSOC INC
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-5625
Practice Address - Country:US
Practice Address - Phone:617-696-5900
Practice Address - Fax:617-696-0363
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78846208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9717269Medicaid
G23541Medicare UPIN