Provider Demographics
NPI:1851553051
Name:RISSING, STACY MARIE (STACY RISSING)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:MARIE
Last Name:RISSING
Suffix:
Gender:F
Credentials:STACY RISSING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6826 WOOD HAVEN PL
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-8560
Mailing Address - Country:US
Mailing Address - Phone:317-402-6495
Mailing Address - Fax:
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:ROOM 0641
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-278-2449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-28
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063834A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200989860Medicaid
IN000000668011OtherANTHEM BCBS
INP00896702OtherRAILROAD MEDICARE
INM400020388Medicare PIN