MEDICARE: DR. MARK BRUCE NISSENBAUM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	122786	NY

General Provider Information

NPI Number	:	1003894502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK BRUCE NISSENBAUM M.D.

Provider Business Mailing Address
First Line	:	3701 LOOP RD
Second Line	:	VA MEDICAL CENTER (679/11)
City	:	TUSCALOOSA
State	:	AL
Zip	:	35404-5015
Country	:	US
Telephone Number	:	205-554-2000
Fax Number	:	205-554-2034

Provider Business Practice Location Address
First Line	:	3701 LOOP RD
Second Line	:	VA MEDICAL CENTER (679/11)
City	:	TUSCALOOSA
State	:	AL
Zip	:	35404-5015
Country	:	US
Telephone Number	:	205-554-2000
Fax Number	:	205-554-2034

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2006
Last Update Date	:	07/09/2007

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