Healthcare Provider Details

I. General information

NPI: 1356506166
Provider Name (Legal Business Name): MARY S KISSWANY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E C ST
BUTNER NC
27509-2530
US

IV. Provider business mailing address

1600 E C ST
BUTNER NC
27509-2530
US

V. Phone/Fax

Practice location:
  • Phone: 919-575-1890
  • Fax: 919-575-1637
Mailing address:
  • Phone: 919-575-1890
  • Fax: 919-575-1637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number000246
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2024-00315
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number25MB08436700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: