Healthcare Provider Details

I. General information

NPI: 1275987638
Provider Name (Legal Business Name): ALISA MO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CHILDRENS DR
COLUMBUS OH
43205-2664
US

IV. Provider business mailing address

300 LONGWOOD AVE BOSTON CHILDREN'S HOSPITAL
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-2000
  • Fax:
Mailing address:
  • Phone: 617-355-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number35.154221
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number291618
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: