Healthcare Provider Details

I. General information

NPI: 1740555986
Provider Name (Legal Business Name): NISSIM S RAKHMINOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6716 OLD PIMLICO RD
BALTIMORE MD
21209-1612
US

IV. Provider business mailing address

6716 OLD PIMLICO RD
BALTIMORE MD
21209-1612
US

V. Phone/Fax

Practice location:
  • Phone: 410-900-0554
  • Fax:
Mailing address:
  • Phone: 410-900-9970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberA3705
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: