NPIMap

Individual provider Active NPI

Tanner J. Nissly, DO

  • Family Medicine Physician
  • Minneapolis, MN
National Provider Identifier
1518131093
Registry record updated Feb 15, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
50925 Issued in MN
Practice address
1020 W Broadway Ave
Broadway Family Medicine
Minneapolis, MN 55411-2504
Phone
(612) 302-8209
NPI assigned
Apr 16, 2008
Last updated
Feb 15, 2013By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 15, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X
Family Medicine Physician 207Q00000X 50925 MN Primary

Addresses

Primary practice location

1020 W Broadway Ave
Broadway Family Medicine
Minneapolis, MN 55411-2504

Mailing address

1020 W Broadway Ave
Broadway Family Medicine
Minneapolis, MN 55411-2504
Phone (612) 302-8209

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20080926000091 MN Practitioner - Family Practice 2769559103 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Kansas City University of Med & Biosciences, College of Osteo Med, 2007
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

2426 W Broadway Ave
Minneapolis, MN 55411-1735
Phone (612) 302-8200

720 Washington Ave SE
Minneapolis, MN 55414-2924
Phone (612) 884-0649

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Skin biopsy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

Practice roles

OrganizationSpecialtyStatusNew patients
University of Minnesota Physicians Current Accepting new patients
North Memorial Health Care CurrentSince Apr 1, 2017 Accepting new patients
North Memorial Health Care Current Accepting new patients
University of Minnesota Physicians CurrentSince Jul 12, 2008 Accepting new patients
University of Minnesota Pediatric Dental Clinic CurrentSince Jul 12, 2008 Accepting new patients
Sibley Medical Center Past Accepting new patients
Cardiothoracic Surgery Clinic of North Ms Past Accepting new patients

Locations

9875 Hospital Dr
Maple Grove, MN 55369
Phone (763) 581-1000

1020 W Broadway Ave
Minneapolis, MN 55411
Phone (612) 302-8200

2426 W Broadway Ave
Minneapolis, MN 55411
Phone (612) 287-0140

420 Delaware St SE
#126
Minneapolis, MN 55455
Phone (612) 626-2378

720 Washington Ave SE
Minneapolis, MN 55414
Phone (612) 883-0649

3300 Oakdale Ave N
Robbinsdale, MN 55422
Phone (763) 520-5048

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1208304000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1360886400000",
    "number": "1518131093",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1020 W BROADWAY AVE",
            "address_2": "BROADWAY FAMILY MEDICINE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554112504",
            "telephone_number": "612-302-8209"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1020 W BROADWAY AVE",
            "address_2": "BROADWAY FAMILY MEDICINE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554112504",
            "telephone_number": "612-302-8209"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "NISSLY",
        "first_name": "TANNER",
        "middle_name": "J.",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-04-16",
        "last_updated": "2013-02-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "50925",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Minneapolis, MN

Sources for this page

Verify at the official NPI Registry.