Healthcare Provider Details

I. General information

NPI: 1629330535
Provider Name (Legal Business Name): KEVIN C SISK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 N 22ND ST
BLAIR NE
68008-1128
US

IV. Provider business mailing address

810 N 22ND ST
BLAIR NE
68008-1128
US

V. Phone/Fax

Practice location:
  • Phone: 402-426-4611
  • Fax: 402-426-4642
Mailing address:
  • Phone: 402-426-2182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2015015493
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1178
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: