Provider Demographics
NPI:1346350808
Name:ABID NISAR
Entity Type:Organization
Organization Name:ABID NISAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ABID
Authorized Official - Middle Name:
Authorized Official - Last Name:NISAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-451-9953
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:ATTNT: CREDENTIALING DEPT.
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:
Practice Address - Street 1:2044 MADISON AVE
Practice Address - Street 2:STE 28
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4641
Practice Address - Country:US
Practice Address - Phone:618-451-9953
Practice Address - Fax:618-451-9322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODD0222OtherRR MEDICARE
MODD0222OtherRR MEDICARE
IL210606Medicare PIN