Basic Information
| Provider Information | |||||||||
| NPI: | 1497950273 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKISIC | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | SEAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805388702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706244443 | ||||||||
| FaxNumber: | 9704904175 | ||||||||
| Practice Location | |||||||||
| Address1: | 1725 E BOULDER ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809095768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193656300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 01/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 0116019544 | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207T00000X | DR-53582 | CO | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.