Provider Demographics
NPI:1851316558
Name:RISSMILLER, SCOTT C (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
Last Name:RISSMILLER
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-0720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000595208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1851316558Medicaid
NC127A9OtherBCBS
NC89127A9Medicaid
SCN00595Medicaid
NCP00280400OtherRAILROAD MEDICARE
NC2280917JMedicare PIN
NC110248103Medicare PIN
NC127A9OtherBCBS
NC2280917KMedicare PIN
H27845Medicare UPIN
NC1851316558Medicaid
NC2280917GMedicare PIN