Provider Demographics
NPI:1720041296
Name:SCHISSEL, SCOTT LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:LEWIS
Last Name:SCHISSEL
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 1:375 BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-6007
Mailing Address - Country:US
Mailing Address - Phone:857-307-0896
Mailing Address - Fax:857-307-0899
Practice Address - Street 1:133 BROOKLINE AVE FL 5
Practice Address - Street 2:HARVARD VANGUARD MEDICAL ASSOCIATES
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-1380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA210319207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2037998Medicaid
MA2037998Medicaid