Healthcare Provider Details

I. General information

NPI: 1982538880
Provider Name (Legal Business Name): MICHAEL E NISSAN MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 N DEARBORN ST
CHICAGO IL
60654-3846
US

IV. Provider business mailing address

540 N DEARBORN ST UNIT 10074
CHICAGO IL
60610-1016
US

V. Phone/Fax

Practice location:
  • Phone: 312-469-0123
  • Fax:
Mailing address:
  • Phone: 312-796-9483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL E NISSAN
Title or Position: OWNER
Credential:
Phone: 773-899-1007