1174546725 NPI number — DR. MICHAEL LEONARD NISSENBAUM PH.D.

Table of content: DR. MICHAEL LEONARD NISSENBAUM PH.D. (NPI 1174546725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174546725 NPI number — DR. MICHAEL LEONARD NISSENBAUM PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NISSENBAUM
Provider First Name:
MICHAEL
Provider Middle Name:
LEONARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174546725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 625
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTEREACH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11720-0625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-737-9500
Provider Business Mailing Address Fax Number:
631-737-9512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 MIDDLE COUNTRY RD
Provider Second Line Business Practice Location Address:
SUITE 28W
Provider Business Practice Location Address City Name:
CENTEREACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11720-3577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-737-9500
Provider Business Practice Location Address Fax Number:
631-737-9512
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TB0200X , with the licence number:  010232 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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