Provider Demographics
NPI:1659305266
Name:GLENN TISMAN M D A MEDICAL
Entity Type:Organization
Organization Name:GLENN TISMAN M D A MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:TISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-789-8822
Mailing Address - Street 1:13025 BAILEY ST
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90601-4211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13025 BAILEY ST
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90601-4211
Practice Address - Country:US
Practice Address - Phone:562-789-8822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19173A261QX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ59344ZOtherBLUE SHIELD
CAW20922Medicare PIN
CAZZZ59344ZOtherBLUE SHIELD
CAG19173AMedicare ID - Type Unspecified