Basic Information
| Provider Information | |||||||||
| NPI: | 1346350808 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ABID NISAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 LACKLAND HILL PKWY | ||||||||
| Address2: | ATTNT: CREDENTIALING DEPT. | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631463572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2044 MADISON AVE | ||||||||
| Address2: | STE 28 | ||||||||
| City: | GRANITE CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620404641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184519953 | ||||||||
| FaxNumber: | 6184519322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | NISAR | ||||||||
| AuthorizedOfficialFirstName: | ABID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6184519953 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | DD0222 | 01 | MO | RR MEDICARE | OTHER |