Provider Demographics
NPI:1952308587
Name:NISSEN, ROGER G (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:G
Last Name:NISSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:880 W CENTRAL RD
Mailing Address - Street 2:SUITE 7100
Mailing Address - City:ARLINGTON HTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2355
Mailing Address - Country:US
Mailing Address - Phone:847-392-7810
Mailing Address - Fax:847-392-7834
Practice Address - Street 1:880 W CENTRAL RD
Practice Address - Street 2:SUITE 7100
Practice Address - City:ARLINGTON HTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2355
Practice Address - Country:US
Practice Address - Phone:847-392-7810
Practice Address - Fax:847-392-7834
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-28
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC44717Medicare UPIN