Provider Demographics
NPI:1316029291
Name:NISSIM, JACK E (M/D)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:NISSIM
Suffix:
Gender:M
Credentials:M/D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 REDLAND CT
Mailing Address - Street 2:SUITE 208
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-3290
Mailing Address - Country:US
Mailing Address - Phone:410-494-7921
Mailing Address - Fax:410-902-8247
Practice Address - Street 1:7505 OSLER DR
Practice Address - Street 2:409
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7736
Practice Address - Country:US
Practice Address - Phone:410-321-5651
Practice Address - Fax:410-583-0134
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0012942207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4800034OtherUNITED HEALTHCARE MCO
MD789201200Medicaid
MD0005 E554OtherBLUE CHOICE/FEP
MD34438002 420AOtherBLUE SHIELD
274550OtherUNITED HEALTHCARE
290010917OtherRAILROAD MEDICARE
MD789201200Medicaid
C57616Medicare UPIN