MEDICARE: DR. JAMES DARRYL BISE D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	054062	GA

General Provider Information

NPI Number	:	1336149988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES DARRYL BISE D.O.

Provider Business Mailing Address
First Line	:	1061 HARMON AVE
Second Line	:	SUITE 2J11D
City	:	FT STEWART
State	:	GA
Zip	:	31314-5604
Country	:	US
Telephone Number	:	912-435-6726
Fax Number	:	912-435-6926

Provider Business Practice Location Address
First Line	:	1061 HARMON AVE
Second Line	:	SUITE 2J11D
City	:	FT STEWART
State	:	GA
Zip	:	31314-5604
Country	:	US
Telephone Number	:	912-435-6726
Fax Number	:	912-435-6926

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	07/08/2007

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