Provider Demographics
NPI:1639160260
Name:HISSONG, SAMUEL L (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:HISSONG
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 1:5423 PENINSULA DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-1633
Mailing Address - Country:US
Mailing Address - Phone:330-904-8716
Mailing Address - Fax:
Practice Address - Street 1:5423 PENINSULA DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-1633
Practice Address - Country:US
Practice Address - Phone:330-904-8716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350301212085U0001X
OH35 0301212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH300070249OtherRAILROAD MEDICARE
OH0302836Medicaid
OH0550674Medicare PIN
OH0302836Medicaid