MEDICARE: OMER J KISSI

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	171W00000X	Contractor	376397	MN

General Provider Information

NPI Number	:	1295015105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMER J KISSI

Provider Business Mailing Address
First Line	:	6916 91ST TRL N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55445-3247
Country	:	US
Telephone Number	:	612-978-4984
Fax Number	:

Provider Business Practice Location Address
First Line	:	6916 91ST TRL N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55445-3247
Country	:	US
Telephone Number	:	612-978-4984
Fax Number	:

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

Provider Enumeration Date	:	08/23/2011
Last Update Date	:	08/23/2011

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Directions to “ OMER J KISSI ” Practice Location

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