Basic Information
| Provider Information | |||||||||
| NPI: | 1679649271 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANISSIAN | ||||||||
| FirstName: | ARA | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 574 GREEN TREE CV | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | COLLIERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380172562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018532021 | ||||||||
| FaxNumber: | 9018532434 | ||||||||
| Practice Location | |||||||||
| Address1: | 574 GREEN TREE CV | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | COLLIERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380172562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018532021 | ||||||||
| FaxNumber: | 9018532434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 01/26/2010 | ||||||||
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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 | 207RA0000X | 29057 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4031484 | 01 | TN | BCBS PROVIDER ID | OTHER |