Provider Demographics
NPI:1326082454
Name:NISSENBAUM, ELIOT M (DO)
Entity Type:Individual
Prefix:
First Name:ELIOT
Middle Name:M
Last Name:NISSENBAUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2719
Mailing Address - Country:US
Mailing Address - Phone:217-224-6423
Mailing Address - Fax:217-221-1344
Practice Address - Street 1:1102 N COUNTY ROAD 700
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IL
Practice Address - Zip Code:62379-3011
Practice Address - Country:US
Practice Address - Phone:217-256-4100
Practice Address - Fax:217-256-3800
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-135963207RC0000X
MO2005000792207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF76074Medicare UPIN