Healthcare Provider Details

I. General information

NPI: 1316029291
Provider Name (Legal Business Name): JACK E NISSIM M./D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7505 OSLER DR 409
TOWSON MD
21204-7736
US

IV. Provider business mailing address

400 REDLAND CT SUITE 208
OWINGS MILLS MD
21117-3290
US

V. Phone/Fax

Practice location:
  • Phone: 410-321-5651
  • Fax: 410-583-0134
Mailing address:
  • Phone: 410-494-7921
  • Fax: 410-902-8247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberD0012942
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberD0012942
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4800034
Identifier TypeOTHER
Identifier State
Identifier IssuerUNITED HEALTHCARE MCO
# 2
Identifier789201200
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer
# 3
Identifier0005 E554
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerBLUE CHOICE/FEP
# 4
Identifier34438002 420A
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerBLUE SHIELD
# 5
Identifier274550
Identifier TypeOTHER
Identifier State
Identifier IssuerUNITED HEALTHCARE
# 6
Identifier290010917
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: