Healthcare Provider Details

I. General information

NPI: 1952327447
Provider Name (Legal Business Name): GLEN A HISS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W 8TH AVE STE 6020
SPOKANE WA
99204-2319
US

IV. Provider business mailing address

105 W 8TH AVE STE 6020
SPOKANE WA
99204-2319
US

V. Phone/Fax

Practice location:
  • Phone: 509-455-5050
  • Fax: 509-789-6204
Mailing address:
  • Phone: 509-455-5050
  • Fax: 509-789-6204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD00023748
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: