MEDICARE: KENNETH RICHARD NISSIM 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	207YS0012X	Sleep Medicine (Otolaryngology) Physician	ME85561	FL
2	207YX0007X	Plastic Surgery within the Head & Neck (Otolaryngology) Physician	036170811	IL
3	207Y00000X	Otolaryngology Physician	ME85561	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447246392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH RICHARD NISSIM M.D.

Provider Business Mailing Address
First Line	:	1120 NW 14TH ST
Second Line	:	5TH FLOOR
City	:	MIAMI
State	:	FL
Zip	:	33136-2107
Country	:	US
Telephone Number	:	305-243-3564
Fax Number	:	305-243-2009

Provider Business Practice Location Address
First Line	:	1253 N ALPINE RD
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61107-2201
Country	:	US
Telephone Number	:	779-696-9201
Fax Number	:	815-397-9667

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

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	12/11/2024

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