Provider Demographics
NPI:1821179714
Name:NISI, RODERICK (MD)
Entity Type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:
Last Name:NISI
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 1:6626 E 75TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 MEDICAL ARTS BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3458
Practice Address - Country:US
Practice Address - Phone:765-298-4720
Practice Address - Fax:765-298-4958
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036283207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64042377Medicaid
INP01512511OtherMEDICARE RR
IN10004427OtherTCARE
IN100176670BMedicaid
IN100009521OtherRAILROAD MEDICARE
IN100176670Medicaid
IN000000085348OtherANTHEM
IN000000085348OtherANTHEM
KY64042377Medicaid
IN10004427OtherTCARE
IN508390Medicare PIN
IN367380Medicare PIN