Provider Demographics
NPI:1053455998
Name:ALAN L NISSENBAUM MEDICAL SERVICES, PC
Entity Type:Organization
Organization Name:ALAN L NISSENBAUM MEDICAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:NISSENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-998-7592
Mailing Address - Street 1:2514 E 65TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-6927
Mailing Address - Country:US
Mailing Address - Phone:718-998-7592
Mailing Address - Fax:718-444-2834
Practice Address - Street 1:2514 E 65TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-6927
Practice Address - Country:US
Practice Address - Phone:718-998-7592
Practice Address - Fax:718-444-2834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177636207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE89065Medicare UPIN