Healthcare Provider Details

I. General information

NPI: 1326082454
Provider Name (Legal Business Name): ELIOT M NISSENBAUM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 11/27/2023
Certification Date: 10/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 N COUNTY ROAD 700
WARSAW IL
62379-3011
US

IV. Provider business mailing address

927 BROADWAY ST
QUINCY IL
62301-2719
US

V. Phone/Fax

Practice location:
  • Phone: 217-256-4100
  • Fax: 217-256-3800
Mailing address:
  • Phone: 217-224-6423
  • Fax: 217-221-1344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036-135963
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2005000792
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: