MEDICARE: DR. ALISA M WASSERMAN D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	5378	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ0241140	OTHER	AZ	BLUE CROSS BLUE SHIELD AZ
2	496978	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1124061916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALISA M WASSERMAN D.C.

Provider Business Mailing Address
First Line	:	725 W ELLIOT RD
Second Line	:	SUITE #115
City	:	GILBERT
State	:	AZ
Zip	:	85233-5301
Country	:	US
Telephone Number	:	480-545-0000
Fax Number	:	480-545-7615

Provider Business Practice Location Address
First Line	:	725 W ELLIOT RD
Second Line	:	SUITE #115
City	:	GILBERT
State	:	AZ
Zip	:	85233-5301
Country	:	US
Telephone Number	:	480-545-0000
Fax Number	:	480-545-7615

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	07/08/2007

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