Provider Demographics
NPI:1396769113
Name:KISSELL, SCOTT K (DPM)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:K
Last Name:KISSELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E BROWN ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-3098
Mailing Address - Country:US
Mailing Address - Phone:570-424-1031
Mailing Address - Fax:570-424-5086
Practice Address - Street 1:175 E BROWN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3098
Practice Address - Country:US
Practice Address - Phone:570-424-1031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004054-L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU58543Medicare UPIN
PA851749Medicare ID - Type Unspecified