Provider Demographics
NPI:1912165671
Name:NISAR MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:NISAR MEDICAL CENTER, INC.
Other - Org Name:NISAR MEDICAL CENTER, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:AZHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:NISAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-279-1757
Mailing Address - Street 1:1407 CHATTANOOGA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2631
Mailing Address - Country:US
Mailing Address - Phone:706-279-1757
Mailing Address - Fax:706-279-1758
Practice Address - Street 1:1407 CHATTANOOGA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2631
Practice Address - Country:US
Practice Address - Phone:706-279-1757
Practice Address - Fax:706-279-1758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042375173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000728494CMedicaid