Provider Demographics
NPI:1184670283
Name:DOCTOR HANY G NISSIEM FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:DOCTOR HANY G NISSIEM FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HANY
Authorized Official - Middle Name:
Authorized Official - Last Name:NISSIEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-395-0620
Mailing Address - Street 1:6565 FOUTH SECTION RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-2416
Mailing Address - Country:US
Mailing Address - Phone:585-395-0620
Mailing Address - Fax:585-395-0622
Practice Address - Street 1:6565 FOURTH SECTION RD
Practice Address - Street 2:SUITE 300
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-2414
Practice Address - Country:US
Practice Address - Phone:585-395-0620
Practice Address - Fax:585-395-0622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227675207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
BA0553Medicare ID - Type Unspecified