MEDICARE: DR. SIDNEY J HANISH M.D.

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	207W00000X	Ophthalmology Physician	MDR8613	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	118695	OTHER		HEALTHLINK
2	0006005882	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1568523199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SIDNEY J HANISH M.D.

Provider Business Mailing Address
First Line	:	1A VILLAGE SQUARE SHOP CTR
Second Line	:
City	:	HAZELWOOD
State	:	MO
Zip	:	63042-1817
Country	:	US
Telephone Number	:	314-731-5656
Fax Number	:	314-731-3215

Provider Business Practice Location Address
First Line	:	1A VILLAGE SQUARE SHOP CTR
Second Line	:
City	:	HAZELWOOD
State	:	MO
Zip	:	63042-1817
Country	:	US
Telephone Number	:	314-731-5656
Fax Number	:	314-731-3215

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

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	03/18/2008

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