Provider Demographics
NPI:1891746962
Name:STISH, EUGENE R (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:R
Last Name:STISH
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 1388
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0388
Mailing Address - Country:US
Mailing Address - Phone:570-288-8881
Mailing Address - Fax:570-288-8065
Practice Address - Street 1:600 PENN ST
Practice Address - Street 2:
Practice Address - City:WEST HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-1514
Practice Address - Country:US
Practice Address - Phone:570-497-4940
Practice Address - Fax:570-497-4942
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037411E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
182834OtherCAPITAL ADVANTAGE
710941282OtherHEALTH AMERICA
002708OtherFIRST PRIORITY HEALTH
PA182834OtherPA BLUE SHIELD
710941282OtherCHAMPUS
710941282OtherAMERIHEALTH
182834OtherCAPITAL ADVANTAGE
182834T2DMedicare ID - Type Unspecified