MEDICARE: MICHAEL D PISANO PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	20010381	IN

General Provider Information

NPI Number	:	1336187103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL D PISANO PHD

Provider Business Mailing Address
First Line	:	550 N MERIDIAN ST
Second Line	:	STE 114
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46204-1207
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2601 COLD SPRING RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46222-2202
Country	:	US
Telephone Number	:	317-274-3960
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	07/08/2007

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