Provider Demographics
NPI:1861479164
Name:BISACCO, STEPHEN J (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:BISACCO
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 1:2918 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-1917
Mailing Address - Country:US
Mailing Address - Phone:814-944-6055
Mailing Address - Fax:814-944-1912
Practice Address - Street 1:2918 6TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-1917
Practice Address - Country:US
Practice Address - Phone:814-944-6055
Practice Address - Fax:814-944-1912
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028089E207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104311OtherUPMC
PA61954OtherTHREE RIVERS-UNISON
PA0008890560001Medicaid
PA197314OtherHIGHMARK
PA1020321OtherGATEWAY
B41110Medicare UPIN
PA0008890560001Medicaid