Provider Demographics
NPI:1710053327
Name:HANISSIAN, GINA R (MD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:R
Last Name:HANISSIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6799 GREAT OAKS RD #250
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38138
Mailing Address - Country:US
Mailing Address - Phone:901-261-0700
Mailing Address - Fax:901-261-0701
Practice Address - Street 1:574 GREENTREE COVE
Practice Address - Street 2:SUITE 101
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017
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:
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Provider Licenses
StateLicense IDTaxonomies
TN31681207RA0000X, 207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4036588OtherBCBS PROVIDER
TN4036588OtherBCBS PROVIDER