MEDICARE: STISH FAMILY PRACTICE PC

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	514293	OTHER	PA	PA BLUE SHIELD
2	002708	OTHER		FIRST PRIORITY HEALTH

General Provider Information

NPI Number	:	1992732689
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STISH FAMILY PRACTICE PC

Provider Business Mailing Address
First Line	:	PO BOX 1388
Second Line	:
City	:	KINGSTON
State	:	PA
Zip	:	18704-0388
Country	:	US
Telephone Number	:	570-288-8881
Fax Number	:	570-288-8065

Provider Business Practice Location Address
First Line	:	600 PENN ST
Second Line	:
City	:	WEST HAZLETON
State	:	PA
Zip	:	18202-1514
Country	:	US
Telephone Number	:	570-497-4940
Fax Number	:	570-497-4942

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EUGENE STISH
Credential	:	MD
Telephone Number	:	570-788-1108

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	03/28/2017

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Directions to “STISH FAMILY PRACTICE PC ” Practice Location

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