Healthcare Provider Details

I. General information

NPI: 1447246392
Provider Name (Legal Business Name): KENNETH RICHARD NISSIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1253 N ALPINE RD
ROCKFORD IL
61107-2201
US

IV. Provider business mailing address

1120 NW 14TH ST 5TH FLOOR
MIAMI FL
33136-2107
US

V. Phone/Fax

Practice location:
  • Phone: 779-696-9201
  • Fax: 815-397-9667
Mailing address:
  • Phone: 305-243-3564
  • Fax: 305-243-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME85561
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number036170811
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License NumberME85561
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: