=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275678450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALISA SURGICAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8422 BUSTLETON AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-722-0958
-----------------------------------------------------
Fax | 215-722-0978
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8422 BUSTLETON AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-722-0958
-----------------------------------------------------
Fax | 215-722-0978
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MRS. TSIVA GUTMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-722-0958
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------