MEDICARE: ALISIA KAYE MACIOCH M.S., LAT, ATC

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	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician	3138	MN
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1568998482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISIA KAYE MACIOCH M.S., LAT, ATC

Provider Business Mailing Address
First Line	:	320 6TH AVE S
Second Line	:
City	:	SOUTH SAINT PAUL
State	:	MN
Zip	:	55075-2624
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1240 COUNTY ROAD B2 W
Second Line	:
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-4338
Country	:	US
Telephone Number	:	651-301-2279
Fax Number	:

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

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	03/05/2026

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