Healthcare Provider Details

I. General information

NPI: 1376793737
Provider Name (Legal Business Name): ALAN L. SISSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 12/31/2020
Certification Date: 12/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 N NORTH BRANCH ST SUITE 210
CHICAGO IL
60642-2473
US

IV. Provider business mailing address

68 FONTAINE CT
BLOOMINGDALE IL
60108-2537
US

V. Phone/Fax

Practice location:
  • Phone: 213-939-5090
  • Fax: 312-640-4496
Mailing address:
  • Phone: 630-283-5646
  • Fax: 630-283-5646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number036088113
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036088113
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036088113
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: