Provider Demographics
NPI:1639167620
Name:BISSELL, MICHAEL G (CPO, FAAOP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:G
Last Name:BISSELL
Suffix:
Gender:M
Credentials:CPO, FAAOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 SAINT LEOS STREET
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-3382
Mailing Address - Country:US
Mailing Address - Phone:336-621-9500
Mailing Address - Fax:336-621-0980
Practice Address - Street 1:3680 WESTGATE CENTER CIRCLE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2935
Practice Address - Country:US
Practice Address - Phone:336-768-1933
Practice Address - Fax:336-768-4869
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1744P3200X
NCCP001225222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4496224OtherPROVIDER # NON HMO AETNA
NC7795063Medicaid
NC0487NOtherBCBS
NC2021053OtherAETNA PROVIDER NUMBER
NC7703164Medicaid
NC9110925Medicaid
NCA9348OtherMEDCOST
NC32953OtherPARTNERS MEDICARE CHOICE
NC0487NOtherBCBS