MEDICARE: DR. AMY GRACE HISE MD

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	207R00000X	Internal Medicine Physician	35073503	OH

General Provider Information

NPI Number	:	1326185406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMY GRACE HISE MD

Provider Business Mailing Address
First Line	:	2103 CORNELL RD
Second Line	:	WRB 4-121
City	:	CLEVELAND
State	:	OH
Zip	:	44106-7286
Country	:	US
Telephone Number	:	216-368-5016
Fax Number	:	216-368-4825

Provider Business Practice Location Address
First Line	:	2103 CORNELL RD
Second Line	:	WRB 4-121
City	:	CLEVELAND
State	:	OH
Zip	:	44106-7286
Country	:	US
Telephone Number	:	216-368-5016
Fax Number	:	216-368-4825

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

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/08/2007

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