Provider Demographics
NPI:1962549626
Name:NISONSON, ANDREA BETH (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:BETH
Last Name:NISONSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6015
Mailing Address - Fax:
Practice Address - Street 1:67 CREEKSIDE PARK CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4810
Practice Address - Country:US
Practice Address - Phone:864-242-4602
Practice Address - Fax:864-242-0129
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26612207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC266125Medicaid
SCSC4889E178Medicare PIN
SCSC4889E178Medicare PIN