Provider Demographics
NPI:1205824067
Name:NISAM, MERRILL RALPH (MD)
Entity Type:Individual
Prefix:
First Name:MERRILL
Middle Name:RALPH
Last Name:NISAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1260 S ELISEO DR
Mailing Address - Street 2:FL 2
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2009
Mailing Address - Country:US
Mailing Address - Phone:415-924-1214
Mailing Address - Fax:415-924-1375
Practice Address - Street 1:100 A DRAKE'S LANDING ROAD
Practice Address - Street 2:SUITE 225
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904
Practice Address - Country:US
Practice Address - Phone:415-924-1214
Practice Address - Fax:415-924-1375
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2018-02-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA49947207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ79929ZMedicaid
CAZZZ79929ZMedicaid