Healthcare Provider Details

I. General information

NPI: 1063104834
Provider Name (Legal Business Name): ALISSA ANASTASIO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 N CANTON CENTER RD
CANTON MI
48187-5097
US

IV. Provider business mailing address

1522 SIMPSON RD EAST MPB D3230
ANN ARBOR MI
48109
US

V. Phone/Fax

Practice location:
  • Phone: 734-844-5400
  • Fax:
Mailing address:
  • Phone: 734-647-1774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5151016065
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: