Provider Demographics
NPI:1881689362
Name:KISSAM, BARBARA ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:ELIZABETH
Last Name:KISSAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:1900 RANDOLPH RD
Practice Address - Street 2:SUITE 1010
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1122
Practice Address - Country:US
Practice Address - Phone:704-316-1155
Practice Address - Fax:704-316-1160
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-011182080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32568300Medicaid
G84568Medicare UPIN