=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790218469
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXIS SERRANO DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2017
-----------------------------------------------------
Last Update Date | 09/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15300 WEST AVE STE 210
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60462-4686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-226-2870
-----------------------------------------------------
Fax | 708-226-2315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 508 N ALEXANDER ST
-----------------------------------------------------
City | PLANT CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33563-3036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | OS19641
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 036171309
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------