Provider Demographics
NPI:1851572358
Name:SISSELMAN MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:SISSELMAN MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SISSELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:516-308-4040
Mailing Address - Street 1:627 BROADWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5031
Mailing Address - Country:US
Mailing Address - Phone:516-308-4040
Mailing Address - Fax:516-804-6386
Practice Address - Street 1:627 BROADWAY
Practice Address - Street 2:SUITE 1
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5031
Practice Address - Country:US
Practice Address - Phone:516-308-4040
Practice Address - Fax:516-804-6386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216154207Q00000X
NY216161207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05215494Medicaid
H22067Medicare UPIN