Basic Information
| Provider Information | |||||||||
| NPI: | 1710053327 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANISSIAN | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6799 GREAT OAKS RD #250 | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012610700 | ||||||||
| FaxNumber: | 9012610701 | ||||||||
| Practice Location | |||||||||
| Address1: | 574 GREENTREE COVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | COLLIERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018532021 | ||||||||
| FaxNumber: | 9018532434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 01/26/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0000X | 31681 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine | 207R00000X | 31681 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 31681 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 4036588 | 01 | TN | BCBS PROVIDER | OTHER |