Cody Wayne Cissom, D.O.
Individual provider Active NPI Internal Medicine Physician · Tupelo, MS
NPI 1104511153 · NPPES record last updated Apr 6, 2023
Key facts
- NPI
- 1104511153
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Internal Medicine Physician 207R00000X
- License
- PENDING (MS)
- Practice address
- 830 S Gloster St
Tupelo, MS 38801-4996 - Phone
- (662) 377-3000
- NPI assigned
- Apr 6, 2023
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20230829002425 | MS | Order and Referring Only - Internal Medicine |
3870956501 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Osteopathy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PENDING | MS | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| North Mississippi Medical Center | Current | Accepting new patients |
Locations
830 S Gloster St
Tupelo, MS 38801
Phone (662) 377-3136
Interoperability endpoints
- codycissom@nmhs.medalliesdirect.net
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | PENDING | MS | Yes |
Addresses
Primary practice location
830 S Gloster St
Tupelo, MS 38801-4996
Mailing address
830 S Gloster St
Tupelo, MS 38801-4996
Phone (662) 377-3000
Other providers in Tupelo, MS
- James Leland Chrisman
- Ashley Christian
- Athena Tiwari Christman
- Robynn Christopherson
- Russell Chumley
- Elishia Clanton
- Chad Clardy
- Lena Clardy
- Brittney Clark
- Caitlin Clark
All providers in Tupelo, MS · Internal Medicine Physician in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 6, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.