Provider Demographics
NPI:1083010201
Name:NISSI FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:NISSI FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARGA
Authorized Official - Middle Name:
Authorized Official - Last Name:NGWANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-540-7597
Mailing Address - Street 1:1810 MULKEY RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1151
Mailing Address - Country:US
Mailing Address - Phone:678-540-7597
Mailing Address - Fax:770-645-9802
Practice Address - Street 1:1810 MULKEY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1151
Practice Address - Country:US
Practice Address - Phone:678-540-7597
Practice Address - Fax:770-645-9802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-16
Last Update Date:2014-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty