MEDICARE: ROGER G NISSEN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician		IL

General Provider Information

NPI Number	:	1952308587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER G NISSEN M.D.

Provider Business Mailing Address
First Line	:	880 W CENTRAL RD
Second Line	:	SUITE 7100
City	:	ARLINGTON HTS
State	:	IL
Zip	:	60005-2355
Country	:	US
Telephone Number	:	847-392-7810
Fax Number	:	847-392-7834

Provider Business Practice Location Address
First Line	:	880 W CENTRAL RD
Second Line	:	SUITE 7100
City	:	ARLINGTON HTS
State	:	IL
Zip	:	60005-2355
Country	:	US
Telephone Number	:	847-392-7810
Fax Number	:	847-392-7834

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	07/08/2007

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