Healthcare Provider Details

I. General information

NPI: 1538111034
Provider Name (Legal Business Name): MICHAEL SCOTT WASSERSTROM DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E CARMEL DR
CARMEL IN
46032-2633
US

IV. Provider business mailing address

2625 OLD VINES DR
WESTFIELD IN
46074-8533
US

V. Phone/Fax

Practice location:
  • Phone: 317-844-7000
  • Fax: 317-844-3268
Mailing address:
  • Phone: 317-896-3304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08001875A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: