Provider Demographics
NPI:1700834504
Name:SISK, ROGER HARLON (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:HARLON
Last Name:SISK
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 1:3600 DALLAS HWY SW
Mailing Address - Street 2:SUITE 290
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1675
Mailing Address - Country:US
Mailing Address - Phone:770-514-8986
Mailing Address - Fax:770-514-0387
Practice Address - Street 1:3600 DALLAS HWY SW
Practice Address - Street 2:SUITE 290
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1675
Practice Address - Country:US
Practice Address - Phone:770-514-8986
Practice Address - Fax:770-514-0387
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021812208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00205213BMedicaid