Provider Demographics
NPI:1679649271
Name:HANISSIAN, ARA JAMES (MD)
Entity Type:Individual
Prefix:
First Name:ARA
Middle Name:JAMES
Last Name:HANISSIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:574 GREEN TREE CV
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-2562
Mailing Address - Country:US
Mailing Address - Phone:901-853-2021
Mailing Address - Fax:901-853-2434
Practice Address - Street 1:574 GREEN TREE CV
Practice Address - Street 2:SUITE 101
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-2562
Practice Address - Country:US
Practice Address - Phone:901-853-2021
Practice Address - Fax:901-853-2434
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29057207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4031484OtherBCBS PROVIDER ID
TN4031484OtherBCBS PROVIDER ID