Provider Demographics
NPI:1558324418
Name:NISSING, MATTHEW H (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:H
Last Name:NISSING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:201 BJC SAINT PETERS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-3091
Mailing Address - Country:US
Mailing Address - Phone:636-916-8200
Mailing Address - Fax:636-926-3303
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-289-6434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002007106207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200603702Medicaid
MO200603702Medicaid
I53343Medicare UPIN