Healthcare Provider Details

I. General information

NPI: 1912165671
Provider Name (Legal Business Name): NISAR MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 CHATTANOOGA AVE SUITE B
DALTON GA
30720-2631
US

IV. Provider business mailing address

1407 CHATTANOOGA AVE SUITE B
DALTON GA
30720-2631
US

V. Phone/Fax

Practice location:
  • Phone: 706-279-1757
  • Fax: 706-279-1758
Mailing address:
  • Phone: 706-279-1757
  • Fax: 706-279-1758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number042375
License Number StateGA

VIII. Authorized Official

Name: DR. AZHAR NISAR
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 706-279-1757