Healthcare Provider Details

I. General information

NPI: 1184857716
Provider Name (Legal Business Name): MICHAEL A. NISSENBAUM, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2009
Last Update Date: 08/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 E MAIN ST
FORT KENT ME
04743-1428
US

IV. Provider business mailing address

PO BOX 1849
LEWISTON ME
04241-1849
US

V. Phone/Fax

Practice location:
  • Phone: 207-834-3155
  • Fax:
Mailing address:
  • Phone: 207-784-2554
  • Fax: 207-777-5363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL A NISSENBAUM
Title or Position: PRESIDENT/ OWNER
Credential: MD
Phone: 207-834-3155