Basic Information
| Provider Information | |||||||||
| NPI: | 1205824067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NISAM | ||||||||
| FirstName: | MERRILL | ||||||||
| MiddleName: | RALPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1260 S ELISEO DR | ||||||||
| Address2: | FL 2 | ||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949042009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159241214 | ||||||||
| FaxNumber: | 4159241375 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 A DRAKE'S LANDING ROAD | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159241214 | ||||||||
| FaxNumber: | 4159241375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 02/26/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | A49947 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | A49947 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | ZZZ79929Z | 05 | CA | MEDICAID |