Provider Demographics
NPI:1780645812
Name:SISTASIS FAMILY PRACTICE,INC.
Entity Type:Organization
Organization Name:SISTASIS FAMILY PRACTICE,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROWENA
Authorized Official - Middle Name:
Authorized Official - Last Name:SISTASIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-633-1212
Mailing Address - Street 1:PO BOX 4247
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27204-4247
Mailing Address - Country:US
Mailing Address - Phone:336-633-1212
Mailing Address - Fax:336-633-1218
Practice Address - Street 1:147 E ACADEMY ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5706
Practice Address - Country:US
Practice Address - Phone:336-633-1212
Practice Address - Fax:336-633-1218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89016FUMedicaid
NC016FUOtherBCBS GROUP NO.
NC2340177Medicare ID - Type UnspecifiedGROUP NO.