Provider Demographics
NPI:1922096122
Name:NISSLEY, FREDERICK P (DO)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:P
Last Name:NISSLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 827783
Mailing Address - Street 2:2ND FLOOR HUDSON BUILDING
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-7783
Mailing Address - Country:US
Mailing Address - Phone:215-707-3646
Mailing Address - Fax:215-707-3644
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:BSMT ROCK PAVILION
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-3646
Practice Address - Fax:215-707-6594
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S009450L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018104530004Medicaid
H23310Medicare UPIN
040979Medicare ID - Type Unspecified