Provider Demographics
NPI:1932344389
Name:MICHAEL NISSEN, MD PC
Entity Type:Organization
Organization Name:MICHAEL NISSEN, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NISSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-772-7000
Mailing Address - Street 1:1317 3RD AVE
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-2995
Mailing Address - Country:US
Mailing Address - Phone:212-772-7000
Mailing Address - Fax:212-772-7001
Practice Address - Street 1:1317 3RD AVE
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-2995
Practice Address - Country:US
Practice Address - Phone:212-772-7000
Practice Address - Fax:212-772-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188503207W00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY86T711Medicare UPIN