Healthcare Provider Details

I. General information

NPI: 1194103036
Provider Name (Legal Business Name): ALEXANDRIA JOANN HASELHORST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2015
Last Update Date: 07/21/2022
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 E ERIE ST
CHICAGO IL
60611-3167
US

IV. Provider business mailing address

1600 W 38TH ST STE 312
AUSTIN TX
78731-6406
US

V. Phone/Fax

Practice location:
  • Phone: 312-238-2870
  • Fax: 312-238-1219
Mailing address:
  • Phone: 512-324-7131
  • Fax: 512-324-7193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberS4490
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: