Provider Demographics
NPI:1952373763
Name:SISCO, STEPHEN RAY (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:RAY
Last Name:SISCO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1055 RIBAUT ROAD
Mailing Address - Street 2:SUITE 30
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5447
Mailing Address - Country:US
Mailing Address - Phone:843-524-8171
Mailing Address - Fax:843-525-6613
Practice Address - Street 1:1055 RIBAUT ROAD
Practice Address - Street 2:SUITE 30
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5447
Practice Address - Country:US
Practice Address - Phone:843-524-8171
Practice Address - Fax:843-525-6613
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC19943208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT39777Medicaid
SCT39777Medicaid