=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881686491
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KURT W NISI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2005
-----------------------------------------------------
Last Update Date | 11/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | NORTH RADIATION THERAPY CTR 3300 OAKDALE AVE N
-----------------------------------------------------
City | ROBBINSDALE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-521-1426
-----------------------------------------------------
Fax | 763-521-1432
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7401 METRO BLVD STE 150
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55439-3026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-920-4915
-----------------------------------------------------
Fax | 952-915-6091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | 36649
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------